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NERVE    PROSTRATION 

AND    OTHER    FUNCTIONAL    DISORDERS    OF 
DAILY    LIFE. 


NERVE  PROSTRATION 

AND  OTHER  FUNCTIONAL  DISORDERS 
OF  DAILY  LIFE. 


BY 

ROBSON  ROOSE,  M.D.,  F.C.S. 

Fellow    of   the    Royal    College    of    Physicians    in    Edinburgh  ; 

Author  of  "  Gout  and  its  Relations,  to  Diseases  of  the  Liver 

AND  Kidneys,"  "Wear  and  Tear  of  London  Life," 

ETC.,    ETC. 


NEW  YORK 
WILLIAM  WOOD  AND  COMPANY 

1888- 


New  Yokk 
William  Wood  and  Company. 


PREFACE. 


In  placing  this  work  before  the  profession,  I  venture  to 
make  a  few  remarks  by  way  of  explanation.  While  fully 
recognizing  the  important  services  rendered  to  medical 
science  by  recent  pathological  discoveries,  I  feel  convinced 
that  the  distinction  between  functional  and  structural  dis- 
orders is  one  which  is  not  yet  obliterated.  Some  sanguine 
observers  think  that  the  term  "  functional "  will  soon  be 
expunged  from  medical  nomenclature,  on  the  ground  that 
every  disturbance  of  function  must  be  due  to  change  of 
structure.  Even  admitting  the  validity,  though  by  no  means 
capable  of  demonstration,  of  this  latter  statement,  it  does 
not  follow  that  the  change  should  always  be  of  such  a 
character  as  to  be  discoverable  by  the  aid  of  any  instrument 
whatever. 

I  regard  the  condition  termed  ''neurasthenia,"  or  *'  nerve- 
prostration,"  as  a  typical  example  of  functional  disorders  ; 
and  in  addition  to  those  complaints  which  fairly  belong  to 
the  same  category,  I  have  included,  a  few  others  in  which 
slight  and  temporary  changes  are  seen  to  occur  in  the 
tissues,  because  under  suitable  treatment  they  rapidly  pass 
away,  leaving  no  trace  of  their  previous  existence,  beyond  a 
certain  weakness  which  shows  itself  in  liability  to  recur- 
rences of  the  same  morbid  state. 


PRUFAGi:. 


Functional  disorders  constitute  a  large  proportion  of  the 
ailments  which  come  before  the  physician  in  daily  practice, 
and  I  hope  that  a  clear  and  comprehensive  account  of  them 
may  prove  acceptable  to  the  profession.  While  not  neglect- 
ing to  make  myself  acquainted  with  the  views  of  others, 
throughout  the  work  my  aim  has  been  to  utilize  the 
experience  acquired  in  the  course  of  a  somewhat  extensive 
practice. 


45,  Hill  Street, 

Berkeley  Square,  W. 
June,  1888. 


CONTENTS. 


INTRODUCTION. 

Functional  Disorders  in  General. 

Functional  and  Organic  Diseases,  Definition  of— Not  to  be  regarded  as 
two  Distinct  Classes— Many  Diseases  thought  to  be  Functional 
now  known  to  be  Organic — Derangement  of  Function  in  the  absence 
of  recognizable  Alterations  of  Structure — Increase  and  Diminution 
of  Excitability— Cardiac  Functional  Disorder— Neuroses  properly 
so-called — Epilepsy  and  Chorea  as  examples  of  Neuroses — Absence 
of  constant  Structural  Lesions  in  Epilepsy— Dr.  Brown-Sequard's 
Views The  Pathogeny  of  Chorea — No  constant  Structural  Altera- 
tions—Dr.  Sturges'  Views — Chorea  a  Functional  Disorder — The 
causes  of  Functional  Derangements— Heredity— Neuropathic  Pre- 
disposition—Education—Physical and  Mental  Causes— Excessive 
use  of  Stimulants— Cold— Pathological  Changes  in  other  Organs— 
Blood-poisons,  as  Syphilis  and  Gout— Disorders  of  Visual  Accom- 
modation and  Refraction  as  causes  of  Nervous  Disturbances— Dr. 
Stevens'  Views —Characters  of  Functional  Nervous  Disorders  as 
distinguished  from  those  of  Organic  Origin  1-23 


SECTION    I. 

FUNCTIONAL    DISOEDFES    OF   TSF    NFEVOUS 

SYSTFM. 

CHAPTER    I. 

Nerve  Prostration — Neurasthenia— Nervous  Debility. 

Nerve  Prostration — Synonyms  and  meaning  of  Term— Nature  and 
Varieties— Prevalence  of  Nerve-prostration  in  England  and  in  the 
United  States -Causes— Dr.  Beard's  Views— Hereditary  Predisposi- 
tion—Training and  Habits  of  Young  Subjects— Influence  of  School- 


viii  CONTENTS. 


work  and  Competitive  Examinations — Symptoms  of  Neurasthenia 
— Symptoms  connected  with  the  Motor  Faculties — Disorders  of  the 
Sensory  Faculties— Spinal  Pain — Neuralgia — Disorders  of  Special 
Senses — Vaso-motor  Disturbances — Disorders  of  the  Circulatory, 
Respiratory,  and  Digestive  Organs — Symptoms  referable  to  the 
Kidneys  and  the  Organs  of  Generation — Signs  of  Mental  Disorder — 
Disorders  of  Sleep — Duration  of  the  Symptoms  of  Neurasthenia — 
Prognosis  and  Diagnosis — Treatment — Relief  of  the  Sleeplessness — 
Freedom  from  Mental  Exertion — Amusements  and  Exercise — Diet 
—Avoidance  of  Tobacco  and  Excess  in  Stimulants — -Tonics  and 
Bathing — Electricity — The  Weir-Mitchell  System — Rest,  Isolation, 
Excessive  Feeding,  Massage,  and  Employment  of  Electricity — Cases 
in  which  Indicated — Details  of  Treatment — Duration  of  Treatment 
and  Results,  with  Illustrative  Cases — Cautions  as  to  Adoption 
of  Treatment  in  Cases  of  Organic  Disease  and  of  Mental  Dis- 
order        25-55 

CHAPTER    II. 

Neurasthenia  Spinalis — Spinal  Irritation. 

Neurasthenia  Spinalis,  a  Functional  Disorder — Its  Presumed  Nature — 
Spinal  Irritation — Causes  of  Spinal  Neurasthenia — Symptoms — 
Causes  of  Spinal  Irritation— Symptoms — Principal  Differences 
between  Spinal  Neurasthenia  and  Irritation — Diagnosis  and  Course 
of  the  two  Conditions — Their  Treatment — Dr.  Brown-Sequard's 
Method  of  Treating  Spinal  Irritation         ...          ...         ...       Z^-^9. 

CHAPTER    III. 

Sleeplessness. 

Sleeplessness  in  Nervous  Disorders — Conditions  requisite  for  Normal 
Sleep — Causes  of  Sleeplessness— Vascular  Excitement — Presence  of 
Imperfectly  Oxidized  Materials  in  the  Blood — Indigestion — Anxiety 
and  Excitement — Cold  and  Heat — Sleeplessness  in  Elderly  Persons 
— External  Causes  of  Sleeplessness — Want  of  Exercise — Treatment 
of  Sleeplessness — Importance  of  Ascertaining  Cause — Question  of 
Diet — Treatment  of  Gouty  Subjects— Hypnotics  for  Cases  Due  to 
Anxiety — Various  Plans  for  Dealing  with  Different  Cases         70-80 


CONTENTS.  ix 


CHAPTER   IV. 

Hysteria. 

Hysteria,  Definition  of  the  Term — Historical  Notices  and  Geographical 
Distribution — Causes — Age  and  Hereditary  Predisposition  to  Nervous 
Disorders — The  Uterine  Theory  of  Hysteria — Local  Irritation  and 
the  State  of  the  General  Health — Exciting  Causes  of  the  Paroxysms 
— Morbid  States  of  System,  as  in  Gout — Symptoms  of  Hysteria, 
their  Great  Variety — Signs  of  Mental  Perversion-  -Alterations  of  the 
Moral  Character— Peculiarities  of  the  Symptoms — The  Hysterical 
Paroxysms — Hystero-Epilepsy,  Symptoms  and  Peculiar  Features  of 
the  Attacks — Other  Forms  of  Motor  Disorder — Paresis — Permanent 
Contraction  and  Rigidity  of  Muscles  and  Limbs — Disorders  of  Sen- 
sation, Hyperaesthesia,  the  Clavus  Hystericus  and  Neuralgia — 
Anaesthesia,  its  Forms — Disorders  of  the  Special  Senses — Disorders 
of  the  Function  of  Digestion — of  Respiration-r-of  the  Circulation — of 
Secretion — The  Urine — Course,  Duration,  and  Results  of  Hysteria — 
Prognosis — Diagnosis — Treatment,  Prophylactic,  Curative,  and 
Symptomatic — Removal  of  Young  Subjects  from  Home  Influences 
Attention  to  Uterine  Complaints  and  to  General  Condition — Treat- 
ment of  Mental  Disorders — Hygienic  Measures — Medicines — Relief 
of  Prominent  Symptoms — Treatment  During  the  Paroxysm — of  the 
Complications — Metallo-Therapeutics — Galvanism  and  Faradism — 
The  Weir-Mitchell  System — Hydropathic  Treatment     ...       "81-128 

CHAPTER   V. 

Epilepsy. 

Epilepsy,  Definition  and  Forms  of — Historical  Notices  and  Geographical 
Distribution  of  the  Disorder—  Causes — Influence  of  Hereditary  Pre- 
disposition— Date  of  First  Attacks — Drunkenness — Sexual  Excesses 
— Lesions  of  the  Nervous  System — Dr.  Brown-Se'quard's  Experi- 
ments— Reflex  Epilepsy — Ocular  Defects  as  a  Cause  of  Epilepsy — 
Dr.  Stevens'  Views — Exciting  Causes — Epilepsy  and  Gout— ]Morbid 
Anatomy  and  Pathology — No  Special  Lesion^ — Seat  of  the  Disorder 
— The  Epileptic  Change — Dr.  Hughlings-Jackson's  Views — Dr. 
Brown-Sequard's  Views — Symptoms  of  the  Paroxysm — The  Pheno- 
mena in  Detail — The  Milder  Forms  of  Epilepsy — Irregular  Forms  — 


CONTENTS. 


The  Epileptoid  States — Reflex  Epilepsy — Jacksonian  Epilepsy — The 
Course  of  the  Disorder — Mental  Symptoms — Diagnosis — Epilepsy 
Distinguished  from  Apoplexy,  Syncope,  Hysteria,  and  Infantile  Con- 
vulsions— Prognosis — Treatment — During  the  Intervals — Hygienic 
Measures— Medicines — The  Bromides,  Atropine,  Zinc,  Silver, 
Vegetable  Tonics  and  Antispasmodics  —  Empirical  Remedies  — 
Electricity — Hydrotherapeutics — Treatment  During    the    Paroxysm 

129-167 

CHAPTER   VI. 

Chorea — St.  Vitus'  Dance. 

Chorea,  Historical  Notices,  Definition  and  Geographical  Distribution  of 
the  Disorder — Causes — Hereditary  Predisposition — Imitation — Age 
and  Sex — Mental  Excitement — Reflex  Causes — Ocular  Disorders, 
Dr.  Stevens'  Views — Connection  between  Rheumatism  and  Chorea 
— Nature  of  Chorea — Drs.  Broadbent,  Kirkes,  and  Dickinson's 
Views — Dr.  Striimpell's  Opinion  that  Chorea  is  a  Functional  Dis- 
order — Symptoms — Evidences  of  Mental  Disorder — Differences  in 
Severity — Analysis  of  Prominent  Symptoms — Duration  of  the 
Disorder — Prognosis,  Diagnosis,  and  Treatment — Necessity  of 
Inquiring  into  Cause — Specific  Remedies,  as  Arsenic,  Zinc,  and 
Strychnine,  Cold  to  the  Spine,  Chloral — Isolation  from  other 
Children 168-186 

CHAPTER   VII. 

Neuralgia. 

Pain,  its  Nature — Sensory  and  Tactile  Nerves,  their  End-Organs,  Fibres, 
and  Nerve-Centres — Varieties  of  Pain — Essential  Features  of 
Neuralgia — Cause  of  Neuralgic  Pain — Changes  in  Nerve-Centres 
— Atrophy  of  Posterior  Roots — Vaso-motor  Disorder — Predisposing 
Causes  of  Neuralgia,  Hereditary  Predisposition,  Debility,  Age,  Sex 
— Exciting  Causes,  Cold  and  Damp,  Injuries,  Pressure  on  Nerves, 
Constitutional  Disorders,  Gout,  Diabetes,  Syphilis,  and  Malarious 
Fevers — Symptoms,  Peculiarities  and  Duration  of  the  Pain,  Remis- 
sions, Intermissions,  and  Recurrences — Locality  of  the  Pain  as  a 
Guide  to  the  Cause — Pain  Extending  Centripetally  and  also  Radiat- 


CONTENTS. 


\ng  along  the  Course  of  Neighbouring  Nerves — Points  Douloureux 
— Cutaneous  Hyperaesthesia  and  Anaesthesia — Motor  Disorder — 
Vaso-Motor  Disturbances  and  Disorders  of  Secretion  and  Nutrition 
— Eruptions  of  Herpes  and  Erythema —  Effects  of  Neuralgia — 
Diagnosis — Treatment — Discovery  of  Cause — Symptomatic  Treat- 
ment— Quinine,  Arsenic,  Salicylate  of  Sodium,  Iodide  of  Potassium 
— Anodynes,  Morphine  and  Atropine — Liniments — Counter-Irrita- 
tion— Electricity — Various  Tonic  Remedies — Neurotomy  and  Neu- 
rectomy— Summary  of  Treatment  ...  ...  ...        187-216 

CHAPTER    VIII. 

Various  Forms  of  Neuralgia. 

I.  Neuralgia    of   the    Trigeminus — Tic    Douloureux. — II.  Inter- 
costal Neuralgia. — III.  Sciatica. 

I.  Causes  of   Tic   Douloureux — Symptoms — Pain— Duration  and   Fre- 

quency of  the  Attacks— rExciting  Causes — Tw^o  Kinds  of  Pain — 
Motor  Disorder — Spasm  of  the  Facial  Muscles-^ Vaso-Motor  and 
Trophic  Disturbances — Neuro- Paralytic  Ophthalmia — Disorder  of 
General  Health — Neuralgia  of  the  Supra-Orbital  Branch — Neuralgia 
of  the  Supra-  and  Inframaxillary  Divisions — Two  Stages  often 
observed  in  Facial  Neuralgia — Diagnosis — Treatment — Causal  and 
Constitutional — Electricity — Anodynes,  Morphine,  Gelsemium — 
Specific  Remedies,  Quinine,  Arsenic,  Iron,  Ammonium  Chloride — 
Liniments — Counter  Irritation — Neurotomy — Neurectomy — Nerve- 
Stretching. 

II.  Intercostal  Neuralgia,  Causes  and  Symptoms — Points  Douloureux — 

Complications  and  Course — Diagnosis — Irritable  Breast  or  Masto- 
dynia — Symptoms  and  Differential  Diagnosis — Treatment  of  Inter- 
costal Neuralgia  and  of  Mastodynia. 

III.  Sciatica,  its  Frequency  and  Causes — Symptoms,  their"  Nature  and 
Variety — Points  Douloureux — State  of  the  Muscles — Vaso-Motor 
and  Trophic  Symptoms — Sugar  sometimes  found  in  the  Urine — 
Electrical  Conditions  of  the  Affected  Parts — Course  and  Duration  of 
Sciatica  —  Diagnosis  —  Prognosis  —  Treatment  —  Question  as  to 
Causation — Rheumatism — Iodide  of  Potassium — Blisters — Hypo- 
dermic   Injections  of    Morphine    and  Atropine — Electricity — Flying 


CONTENTS. 


Blisters  —  Acupuncture — Hot    Baths  —  Warm   Applications  —  The 
Scotch  Douche — Hot  Sand-Baths — Massage — Nerve-Stretching 

317-259 

CHAPTER    IX. 

Articular  Neuroses — Neuralgia  of  the  Joints. 

Nature  and  Pathogeny  of  Neuralgia  of  the  Joints — Predisposing  and  Ex- 
citing Causes — Symptoms — Cutaneous  Hyperaesthesia — Position  of 
the  Limb— Joints  usually  Affected — Course  and  Progress  of  Neu- 
ralgia of  Joints- — Diagnosis — Anaesthesia  often  Necessary — Mental 
Condition  of  the  Patient — Results  of  Application  of  Bandages,  etc. — 
Exaggerated  Patellar  Reflex  in  Hysterical  Contraction  of  the  Knee- 
joints — Pain  in  Knee  an  Occasional  Symptom  of  Hip-Joint  Disease 
— Treatment,  Constitutional  and  Local — Massage,  Douches,  Baths, 
etc. — Electricity — Use  of  the  Limb  to  be  Recommended         260-267 

CHAPTER  X. 

Headache. 

Pain  in  Head  often  Symptomatic — Associated  with  Cerebral  Hyperaemia, 
Active  and  Passive—  Causes  and  Consequences — Anaemic  Headache 
— Symptoms — Headaches  in  Neurasthenia  and  Nervous  Subjects 
Generally — Sympathetic  Headache — Indigestion  as  a  Cause  of 
Headache — Rheumatic  and  Gouty  Headache — Headache  due  to 
Intemperance — Headache  in  Hysterical  Subjects — Pains  in  the  Head 
due  to  Syphilis — Headache  due  to  Disorders  of  the  Refractive 
Apparatus  of  the  Eye — Diagnosis  of  Headache — Treatment  of  the 
Hyperaemic  and  Anaemic  Forms — Remedies  for  Neurasthenic  and 
Rheumatic  Cases — Empirical  Treatment  ...  ...        268-281 

CHAPTER   XI. 

Hemicrania — Migraine — Megrim. 

Frequency  of  Hemicrania — Its  Prominent  Features — Premonitory  Sym- 
ptoms— Symptoms  of  the  Attack — Phenomena  indicative  of  Vaso- 
Motor  Disturbance — Tv^'o  Forms — Disorders  of  Vision — Periodicity 
of  Migraine — Length  of  Paroxysms — Causes  of  Migraine — Sex,  Age, 
Hereditary    Tendency,    Gouty    Predisposition — Exciting    Causes — 


CONTENTS.  xiii 


Anxiety,  Over-exertion,  Impressions  on  Certain  Nerves  of  Special 
Sense,  Derangement  of  Stomach,  Relation  of  Gastric  Symptoms  to 
Migraine,  Insomnia — Pathogeny  of  INIigraine — The  Spastic  Form — 
Pain  due  to  Spasm  of  the  Muscular  Coat  of  the  Vessels — Fluctua- 
tions in  the  Supply  of  Arterial  Blood  as  Causes  of  Irritation — Dr. 
Liveing's  Theory  of  the  Irregular  Accumulation  and  Discharge  of 
Nerve  Force — Migraine  thought  by  some  to  be  only  a  Variety  of 
Trigeminal  Neuralgia  —  Diagnosis  —  Prognosis  —  Treatment  —  A 
Course  of  Quinine — Aperients — The  Iodides  with  the  Alkaline  Car- 
bonates for  Gouty  Subjects — Strychnine,  Arsenic,  Oxide  of  Zinc,  and 
Nitrate  of  Silver,  Attention  to  Diet  and  Habits — Question  with 
regard  to  Stimulants,  Sleep,  and  Exercise — Change  of  Air  and 
Scene — Precautionary  Measures  when  a  Paroxysm  is  Threatening — 
Rest,  Darkness,  and  Warmth — Stimulants,  Nux  Vomica,  Sodium 
Bicarbonate — Antipyrin — Treatment  during  the  Attack — Darkness 
and  Quiet,  Cold  to  the  Head,  and  Warm'th  to  the  Feet — Amyl 
Nitrite  —  Ergot  —  Cannabis  Indica — Chloral — Morphine — Caffeine 
and  Guarana — Galvanism  ...  ...  ...  ...       282-304 

CHAPTER  XII. 

Vertigo — Giddiness. 

Vertigo  as  a  Symptom  of  Organic  Diseases  of  the  Nervous  System — In 
Diseases  of  the  Stomach  and  Liver — In  Affections  of  the  Eyes  and 
Ears — In  Debility  and  Anaemia,  and  Functional  Disorders  of  the 
Nervous  System — Toxic  Forms  as  in  Gout — Definition  and  Kinds 
of  Vertigo — Gastric  Vertigo,  Symptoms  and  Treatment — Ocular 
Vertigo — Aural  Vertigo — Vertigo  of  Anaemia,  Neurasthenia,  Hys- 
teria, Epilepsy,  and  Hemicrania — Vertigo  in  Gouty  Subjects 

305-319 
CHAPTER   XIII. 

Writer's  Cramp  and  Allied  Disorders. 

Writer's  Cramp,  Peculiarities  of — Persons  Most  Prone  to  Suffer — Patho- 
logy— Symptoms,  Three  Forms  :  Spastic,  Tremulous,  and  Paralytic 
— Mixed  Forms — Allied  Disorders — Diagnosis — Treatment  — Rest — 
Wolff's  Method — Galvanism — Attention  to  General  Health — Local 
Measures  — Counter-irritation — ^Mechanical  Appliances  320-329 


xiv  CONTENTS. 


CHAPTER   XIV. 

Facial  Paralysis. 

Forms  of  Functional  Paralysis — Rheumatic  Paralysis — Paralysis  of  the 
Facial  Nerve,  due  to  Cold  and  other  Influences — Symptoms,  Subjec- 
tive and  Objective — Loss  of  the  Sense  of  Taste — Auditory  Symptoms 
— Electrical  Reactions  of  the  Paralyzed  Parts — Diagnosis  of  Facial 
Paralysis — Determination  of  the  Site  of  the  Lesion — Prognosis — 
Treatment 330-340 

CHAPTER    Xy. 

Hypochondriasis. 

Hypochondriasis,  Definition  and  Forms— Causes — Hereditary  Predis- 
position— Habits  of  Life — Gout — Abdominal  and  Sexual  Disorders 
— Subsidiary  Causes — Symptoms — Influence  of  Attention — Mental 
Disorder — Illusions — Disorders  of  Sensation — Disorders  of  Motion — 
Impotence — Vaso-Motor  Disturbances — Course  and  Prognosis — 
Diagnosis — Treatment — Existing  Ailments  to  be  Attended  to — 
Gouty  Cases — Rest  and  Recreation — Change  of  Air  and  Scene,  and 
Suitable  Occupation         ...  ...  ...  ..  ...       341-351 


SECTION    II. 

FUNCTIONAL    DISORDERS    OF    TSF    ORGANS    OF 
CIRCULATION. 

INTRODUCTORY     CHAPTER. 

Peculiar  Features  of  Functional  Disorders  of  the  Heart — Difference 
between  Functional  and  Organic  Affections — Symptoms  of  Func- 
tional  Disorders,  Either  the  Movements  or  the  Sensations  of  the 
Organ  Affected — Disturbances  of  Rhythm — Causes  of  Functional 
Disorder  of  the  Heart — Predisposing  Causes— Dr.  Shapter's  Classifi- 
cation— Symptoms  often  Accompanying  Palpitation — Diminished 
Impulse  Associated  with  Depression  and  Anxiety — Necessity  of 
Examination  into  Habits  and  Circumstances — Inorganic  Murmurs 


CONTENTS. 


— Cases  of  Cardiac  Exhaustion — Dr.  Hartshorne's  Experience — The 
Irritable  Heart — Study  of  the  Cardiac  Nervous  Apparatus — The 
Intra-Cardiac  Ganglia — The  Pneumogastric  Nerves — Cardiac  Sen- 
sory Fibres — The  Sympathetic  Nerve — The  Depressor  Fibres  of  the 
Vagus — Summary  of  the  Circumstances  Afifecting  the  Frequency  of 
the  Heart's  Action  ...  ...  ...  ...  '.,.       .353-372 

CHAPTER    II. 

Palpitation  of  the  Heakt. 

Cardiac  Palpitation,  Description  of — General  Symptoms — Alteration  in 
Sounds  of  Heart  and  in  Pulse — Condition  of  the  Respiration  and  of 
the  Features — Subjective  Sensations — Duration  of  Attacks — Causes 
of  Palpitation — Nervous  and  Toxic  Causes — Exhaustion — Reflex 
Irritation — Exciting  Causes — Diagnosis — Prognosis — Treatment — 
Relief  of  Paroxysms  and  Prevention  of  Recurrence — Position,  Cold 
to  Chest,  Medicines — Treatment  of  Nervous  ^Subjects — Treatment  of 
Palpitation  Due  to  Indigestion  and  Gout — During  the  Intervals — 
Various  Points  to  be  Attended  to...  ...  ...  ...       373-387 

CHAPTER    III. 

Syncope — Swoonjng — Faintness. 

Syncope,  Definition  and  Symptoms — Incomplete  Attacks  or  Faintness — 
—  Duration  of  Attacks — Causes,  the  Nervous  System,  the  State  of 
the  Heart,  the  Condition  of  the  Blood — Impressions  on  the  Nervous 
System — Direct  Effects  on  the  Heart — Mechanical  Causes,  Poisons 
—Syncope  Resulting  from  Loss  or  Deficiency  of  Blood — Mixed 
Cases — Duration  of  Attacks — Syncope  Distinguished  from  Epilepsy, 
Apoplexy,  Shock,  Concussion,  and  Poisoning — Prolonged  Syncope — 
Prognosis — Treatment — Restoration  of  Action  of  Heart,  and  Supply 
of  Blood  to  the  Brain        ...  ...  ...  ...  ...       388-400 

CHAPTER   IV. 

Neurasthenia  of  the  Heart. 

Weakness  of  the  Heart  in  Neurasthenia — Symptoms — Palpitation,  Pain, 
and  Sleeplessness — Hypochondriasis — Special  Cardiac  Symptoms — 
Periodicity  Sometimes  Noticed — Causes  of  Cardiac  Neurasthenia — 
Prognosis  and  Treatment  ...  ...  ...  ...       401-406 


xvL  CONTENTS. 


CHAPTER    V. 
Angina  Pectoris — Neuralgia  of  the  Heart. 

Angina  Pectoris,  Definition  of — Peculiarities  and  Symptoms  of  the 
Attacks — The  Cardiac  Pain  and  Pulsations — Sounds  of  the  Heart 
— Respiratory  Symptoms  and  Expression  of  Countenance — Pains  in 
the  Shoulder  and  Arms — Indications  of  Vaso-Motor  Disorder — 
Measures  Adopted  by  Patients  to  Relieve  Distress — Results  of  Attack 
and  State  of  Health  in  the  Intervals — Causes  of  a  Fatal  Termina- 
tion— Causes  of  Angina,  Essential  and  Symptomatic — Influence  of 
Tobacco  Smoking — Lesions  Found  after  Death  in  some  Cases — 
Nature  of  the  Disorder — The  Nervous  Apparatus  of  the  Heart — 
Three  Sources,  the  Cardiac  Ganglia,  the  Pneumogastric,  and  the 
Sympathetic — Vaso-Motor  Angina  Pectoris — Diagnosis — Prognosis 
— Treatment,  Relief  of  Attacks  and  During  Intervals — Subcutane- 
ous Injection  of  Morphine — Inhalations  of  Nitrite  of  Amyl — Nitro- 
Glycerine  Internally — Stimulants — Hygienic  Measures — Arsenic — 
Treatment  of  Gouty  Subjects       „..  ...  ...  i..       407-423 


SECTION   III. 

FUNCTIONAL    DISORDERS    OF    THE    RESPIRATORY 

ORGANS. 

INTRODUCTORY     CHAPTER. 

Functional  Disorders  of  Respiration — Nerves  of  Sensation  or  Motion 
Implicated — Disorders  of  the  Voice — Hoarseness — Aphonia  and  its 
Causes — Laryngeal  Growths,  Catarrhal  Swelling,  Paralysis  of  the 
Laryngeal  Muscles,  Hysteria,  Anaemia — Dysphonia  Clericorum — 
Insufficient  Stream  of  Air — Treatment  of  Hoarseness  and  Aphonia 
— Inhalations — Tonics — Mineral  Waters — Faradism — Anaesthesia 
and  Hyperaesthesia  of  the  Respiratory,  Nerves — Neuralgia  of  the 
Larynx — Treatment — Nervous  Cough — Symptoms — Causes — Con- 
nection between  Cough  and  Affections  of  the  Ear — Treatment 

425-438 


CONTENTS. 


CHAPTER   II. 

Laryngismus  Stridulus — Laryngeal  Asthma. 

Laryngismus  Stridulus — Nature  and  Causes — Age,  Rickets  and  Scrofula, 
Heredity,  Malnutrition — Exciting  Causes  of  Attacks — Symptoms  of 
a  Paroxysm — Spasm  of  Larynx — Carpopedal  Contractions,  Eclamp- 
sia— Anatomical  Changes — Theories  as  to  Nature  of  Complaint — 
Sir  M.  Mackenzie's  Views — Diagnosis — Prognosis — Treatment, 
Prophylactic  and  During  Attacks — Chloroform,  Musk,  Purgatives, 
Bromide  of  Potassium,  etc.  ...        •...  ...         ...       439-447 

CHAPTER    III. 

Asthma. 

Asthma,  Meaning  of  Term — Causes — Age,  Constitutional  Conditions, 
Weather,  and  Climate — Idiopathic  and  Symptomatic  Asthma — 
Bronchial  and  Nasal  Affections — Dust  and  Emanations  of  Various 
Kinds — Abdominal  Disorders — Renal  Affections — Asthma  and  Gout 
— Symptoms  of  Asthma— Objective  Symptoms  During  an  Attack 
— Pathogeny, — Sequelse—  Diagnosis — Prognosis — Treatment  during 
the  Paroxysm,  Narcotics  and  Antispasmodics — During  the  Intervals 
— Removal  of  Causes — Inhalation  of  Oxygen  and  of  Condensed  Air 
— Change  of  Air — Treatment  of  Gouty  Cases — Purgatives — Alkalies 
— Iodide  of  Potassium^ — Electricity         ...  ...  ...       448-471 

CHAPTER   IV. 

Hay-Asthma — Hay-Fever. 

Hay-Asthma,  Questions  as  to  its  Nature — General  Description — First 
Recognized  by  Dr.  Bostock — Causes,  Predisposing  and  Exciting — 
The  Pollen  of  Grasses,  and  of  Various  Cereals — Dr.  Blackley's  Ex- 
periments— Symptoms — Affections  of  the  Nose,  Eyes,  and  Throat — 
Cough  and  Difficulty  of  Breathing — Appearances  of  the  Affected 
Parts — Diagnosis — Treatment — Prophylactic  and  Curative 

472-480 


CONTIJNTS. 


SECTION     IV. 

FUNCTIONAL  DISORDERS    OF    TSE    ORGANS    OF 
DIGESTION. 

INTRODUCTORY     CHAPTER. 

Varieties  of  Functional  Disorders  now  to  be  Discussed — Affections  of  the 
Stomach,  Intestines,  and  Liver — Their  Peculiarities  and  Causes — 
Errors  in  Diet — Excess  of  Nitrogenous  Food — Kidney  Affections  as  a 
Secondary  Result — Deficient  Supply  of  Nitrogenous  Materials — 
Bread  as  a  Food — Influence  of  the  Tannin  of  Tea  on  Salivary  Diges- 
tion— Effects  of  Improper  Food — Peculiarities  in  Certain  Individuals 
— Effects  of  Nervous  Exhaustion — Spasm  of  the  Stomach  and  In- 
testines— Spasm  of  the  CEsophagus — Perversion  of  Gastric  and  In- 
testinal Secretion — Effects  of  Nervous  Influence — Hepatic  and 
Pancreatic  Secretion — Effects  of  Nervous  Influence  on  Intestinal 
Movements — Effects  of  Alterations  in  the  Blood  Supply — Enumera- 
tion of  the  Symptoms  of  Functional  Disorders  of  the  Stomach  and 
Intestines      ...  ...  ...  ...  ...  ...  ...     481-494 

CHAPTER     II. 

Dyspepsia — Indigestion. 

Functions  of  Stomach  and  Intestines — Mechanical  Actions  and  Chemical 
Changes  Therein — Meaning  of  Term  Dyspepsia — Relations  with 
Catarrh — The  Vascular  Apparatus  of  the  Stomach — Strong  and 
Weak  Digestions  —  Causes  of  Dyspepsia  —  Faults  Connected 
with  the  Diet — Use  of  Fluids,  Alcohol,  Tobacco — Positions  of  the 
Body,  Exertion  after  Meals,  Nervous  Excitement,  Disorders  of 
Stomach — Anatomical  Changes  in  Catarrh — Symptoms  of  Acute 
Dyspepsia — Chronic  Forms — Influence  on  the  Mental  Condition — 
Results  of  Repeated  Attacks — Matters  Ejected  from  the  Stomach — 
Formation  of  Organic  Acids — Increase  of  Salivary  Secretion — Pyrosis 
— Constipation — Diarrhoea — The  Urine  and  Skin — General  Condi- 
tion  of  the  Patient— Cardiac  Symptoms — Vertigo — Course  and 
Duration — Diagnosis — Prognosis — Treatment  of  Acute  Attacks — 
Rest — An  Emetic — Alkalies — Laxatives — Treatment  of  Chronic 
Forms — Attention  to  Diet — The  State  of  the  Teeth — Articles  of  Diet 


CONTENTS.  xix 


Suitable — Fluids — Milk  Diet — Treatment  of  Constipation,  Laxa- 
tives Suitable — Aloes,  Cascara,  .Salines — Stronger  Purgatives — 
Hygienic  Measures  as  Change  of  Air,  Exercise,  Baths — Medicines 
such  as  Acids,  Alkalies,  Bismuth,  and  Charcoal — Treatment  of 
Irritative  Dyspepsia — Arsenic,  Ipecacuanha — Question  of  Health- 
Resorts       495-534 

CHAPTER   III. 

Nervous  Dyspepsia  and  Perverted  Appetite. 

■Causes  of  Nervous  Dyspepsia — Symptoms  —  Gastric  and  Nervous 
Troubles — Diagnosis — Treatment — Diet  and  Regimen — Exercise — 
Drugs,  Quinine,  Arsenic,  and  Belladonna — The  Weir-Mitchell  Treat- 
ment as  for  Neurasthenia — Perversion  of  Appetite — Appetite  Ab- 
normally Increased — Symptoms  and  Causes — Treatment — Diminu- 
tion and  Loss  of  Appetite  or  Anorexia — Case  and  Treatment — 
Depraved  Appetite — Symptoms  and  Treatment  ...       53.5-545 

CHAPTER    IV. 

Gastralgia — Gastrodynia"— Cardialgia. 

Pain  in  the  Stomach  as  a  Definite  Complaint — Causes — Conditions 
under  which  it  Occurs — Gastralgia  in  Gouty  Subjects — In  Loco- 
motor Ataxy — Of  Reflex  Origin — Due  to  Rena!  Disease^  Symptoms 
— Duration  and  Exciting  Causes  of  Paroxysms — Spasmodic  Form 
of  Gastralgia — Diagnosis,  from  Intercostal  Neuralgia,  Myalgia, 
Colic,  Peritonitis,  Gall-stones,  etc.,  and  from  Gastric  Disorders,  as 
Ulcer,  Cancer,  and  Catarrh — Prognosis  and  Treatment — Laxatives 
— Quinine — Arsenic — Alkalies — Ipecacuanha — Morphine,  Strych- 
nine, Chloral,  Electricity — Treatment  of  Gouty  Cases  ...        546-559 

CHAPTER  V. 

Nervous  Vomiting  and  Eructations. 

Phenomena  of  Vomiting — Nervous  Vomiting — Reflex  Causes — Mental 
Impressions — Organic  Nervous  Lesions^Peripheral  Irritation — Dis- 
orders of  the  Abdominal  Organs — Disorders  of  the  Sexual  Organs — 
Toxic   Causes — Symptoms   of  Nervous  Vomiting — Diagnosis  and 


CONTENTS. 


Prognosis — Treatment,  Causal  and  Symptomatic — Ice,  Anodynes^ 
Cocaine,  Bromide  of  Potassium,  etc. — Nervous  Eructations — Sym- 
ptoms— Sources  of  the  Gas — Case  of  Nervous  Eructations — Treat- 
ment ...  ...  ...  ...  ...  ...  ...       560-571 

CHAPTER   VI. 

Enteralgia — Colic — Neuralgia  Mesent erica. 

Colic,  Definition  and  Causes — Irritating  Articles  of  Food — Gaseous  Dis- 
tension of  the  Abdomen — Drastic  Purgatives — Lead  and  Copper — 
Colic  as  a  Symptom  of  Nervous  Disorders,  and  in  Connection  with 
Gout  and  Rheumatism — Colic  due  to  Cold — Symptoms  of  Colic — 
Diagnosis — Prognosis — Other  Horms  of  Colic — Neuralgia  of  the 
Bowels — Nervous  Diarrhoea — Treatment — Aromatics  and  Stimu- 
lants —  Warmth  Locally — Opiates  —  Ipecacuanha —  Purgatives  — 
Enemata — Morphine  Hypodermically — Treatment  of  Gouty  and 
Rheumatic  Cases — Treatment  of  Neuralgia  of  the  Bowels — Ano- 
dynes, Tonics,  Improvement  of  General  Health,  etc.     ...       572-587 

CHAPTER    VII. 

Constipation. 

Prevalence  of  Constipation — Causes,  Age,  Sex,  Occupation,  Want  of 
Exercise,  Neglect — Too  Little  Fluid  in  Diet — Normal  Action  of 
Bowels — Contents  of  Faeces — Defaecation — Consequences  of  Consti- 
pation—Chlorosis—Other Causes  of  Constipation  and  Disorders 
with  which  Associated — Surgical  Causes — Habitual  Constipation, 
Influence  of  Drastic  Purgatives —Insufficiency  and  Improper  Quality 
of  Food — Diagnosis — Treatment  of  Constipation — Of  Occasional 
Attacks — Castor  Oil,  Salines,  Rhubarb,  Calomel  and  Senna— Ene- 
mata— Faradism — Treatment  of  Chronic  Constipation — Attention 
to  Habits — Necessity  of  Daily  Visit  to  the  Closet— Regulation  of 
Diet — Fruits  and  Vegetables,  Fluids — Laxatives,  Aloes  and  Cascara 
— Castor  Oil,  Senna,  and  Bitter  Tonics — Nux  Vomica — Salines, 
Mineral  Waters,  Friedrichshall,  Rubinat-Condal,  etc. — Carlsbad 
Salts— Hepatic  Stimulants  as  Podophyllin,  Iridin,  Euonymin,  and 
Leptandrin — Nitro-Muriatic  Acid — Belladonna — Enemata,  their 
Drawbacks — Other  Remedies — Caution  as  to  Use  of  Laxatives 

588-613 


CONTENTS.  Xxi 


CHAPTER  VIII. 

Diarrhoea. 

Diarrhcea,  Conditions  for  its  Production — Causes,  Food,  Cold,  Mental 
Excitement,  Summer  Diarrhoea — Diarrhoea  Accompanying  Intes- 
tinal Lesions  and  Various  Morbid  Conditions — Persons  most  Subject 
to  Attacks — Anatomical  Appearances — Symptoms  in  Adults — In- 
fluence on  General  Condition — Severe  Attacks — Diagnosis — Treat- 
ment, Question  as  to  Arresting  Discharges — Sometimes  Desirable 
to  Facilitate  them — Castor  Oil,  Sulphate  of  Sodium,  Rhubarb,  and 
Calomel — For  Checking  Diarrhoea,  Opium,  Aromatics  and  Astrin- 
gents, Camphor,  Warmth,  Stimulants — Chronic  Diarrhcea — Diet 
and  Regimen — Rest — Diarrhoea  in  Children — Causes  of  Frequency 
— Disorders  of  Digestion — Complications — ^Treatment,  Cautions  as 
to  Use  of  Opiates — Warm  Baths,  Stimulants,  Flannel  to  Surface — 
Diet— Enemata  of  Warm  Water — Calomel — Cautions  as  to  Exces- 
sive Feeding — Chronic  Diarrhcea — Diet,  Flannel  and  Warmth — 
Grey  Powder,  Vegetable  Astringents,  Chalk,  Bismuth,  Perchloride 
of  Mercury,  Arsenic,  Iron  ...         ...  ...         ...       614-633 

CHAPTER   IX. 

Functional  Disorders  of  the  Liver. 

Functions  of  Liver—  Secretion  of  Bile,  Formation  of  Glycogen  and  Meta- 
bolic Processes — Functional  Disorders  — Hepatalgia — Circulatory 
Disorder — Hyperasmia,  Causes  and  Symptoms — Treatment — Bilious- 
ness and  a  Bilious  Attack — Causes  and  Treatment — Disorders  of 
the  Secretory  Function — The  Saliva  as  a  Test — Excessive  Secretion 
of  Bile — Symptoms  and  Treatment — Diminished  Secretion  of  Bile — 
Symptoms  and  Treatment — Vitiated  Secretion  of  Bile — Symptoms 
and  Treatment — Disorders  of  the  Metabolic  Processes — Evidence 
that  Urea  is  Formed  in  the  Liver — Lithaemia  as  a  Result  of  Func- 
tional Hepatic  Disorder — Symptoms,  Causes,  and  Treatment — Albu- 
minuria in  these  Cases — Its  Causes,  Import,  and  Treatment — 
Cutaneous  Affections  in  Lithaemia  and  their  Treatment        634-661 


NERVE    PROSTRATION 

AND    OTHER  FUNCTIONAL    DISORDERS    OF 
•      DAILY  LIFE. 


INTRODUCTION. 

FUNCTIONAL  DISORDERS   IN  GENERAL. 
Functional    and   Organic   Diseases,    Definition   of — Not    to    be 

REGARDED    AS   TWO    DiSTINCT    CLASSES MaNY  DISEASES  THOUGHT 

TO  BE  Functional  now  known  to  be  Organic — Derangement  of 
Function  in  the  absence  of  recognizable  Alterations  of 
Structure — Increase  and  Diminution  of  Excitability — 
Cardiac  Functional  Disorder — Neuroses  properly  so-called 
— Epilepsy  and  Chorea  as  examples  of  Neuroses — Absence  of 
constant  Structural  Lesions  in  Epilepsy — Dr.  Brown- 
Sequard's  Views — The  Pathogeny  of  Chorea — No  constant 
Structural  Alterations — Dr.  Sturges'  Views — Chorea  a 
Functional  Disorder — The  causes  of  Functional  Derange- 
ments—Heredity— Neuropathic  Predisposition — Education — 
Physical  and  Mental  Causes — Excessive  use  of  Stimulants — 
Cold — Pathological  Changes  in  other  Organs — Blood- 
poisons,  as  Syphilis  and  Gout- — Disorders  of  Visual  Accommo- 
DATJON  and  Refraction  as  causes  of  Nervous  Distu-rbances — 
Dr.  Stevens'  Views — Characters  of  Functional  Nervous  Dis- 
orders as  distinguished  from  those  of  Organic  Origin. 


In  the  various  attempts  to  classify  diseases,  the  terms 
'^  structural  "  or  "  orcranic  "  on  the  one  hand,  and 
'^  functional  ^'  on  the  other,  have  always  found  a  place. 
Their  general  meaning  is  obvious  ;  the  former  term 
being  applied   to  diseases  in  which  the  affected  part  is 

the  seat  of  alterations  more  or  less  easily  demonstrable, 

I 


2  FUNCTIONAL  AND  ORGANIC  DISORDERS. 

while  a  "  functional  "  disease  or  disorder  is  one  which 
depends  on  an  unnatural  or  irregular  action  of  a  part, 
unconnected  with  any  apparent  injury  to  its  structure. 
The  conditions  embraced  by  these  descriptions  are  there- 
fore contrasted_,  and  the  belief  was  once  prevalent  that 
a  distinct  line  of  demarcation  existed  between  the  two 
classes.     No  separation  of  this  kind  can_,  however_,  be 
made.     The  progress  of  discovery  has  indeed  effected  a 
great  change  in  the  relative  numbers   of  the  diseases 
thus  classified,,  and  many  disorders  formerly  believed  to 
be  functional    are  now  known  to   be  organic.     In  no 
department  of  pathology  has  this   change  been  more 
marked    than    in    disorders    of    the    nervous    system. 
During  the  last  quarter  of  a  century    many   of   these 
affections  have  been  transferred  from  the  "  functional  ^^ 
to  the  "  organic ''  class,  and  the  progress  thus    made 
justifies  the  hope  that  the  former  class  will  become  less 
and  less  numerous  as  time  goes  on.     It  is  sufficient  to 
cite  a  recent  and  striking  example.   Not  many  years  ago 
the  disorder  known  as  infantile  paralysis  was  described 
as   '' essential/'   i.e.,    '^'"functional."     It  has,  however, 
been  shown  by  microscopical  examination  that  in  this 
disease  the  spinal  cord  and  its  nerves  are  the  seat  of  a 
variety    of  lesions,   such   as    atrophy    of   the   anterior 


DYNAMIC  DERANQJEMJENTS  OF  NERVE-CENTRES.  3 

cornua  and  of  the  anterior  columns,  and  granular  dis- 
integration and  atrophy  of  the  anterior  nerve-roots. 

Other  instances  might  be  adduced  to  show  that  in  all 
probability  disorders  still  regarded  as  functional  are 
really  dependent  upon  structural  changes  which  our  pre- 
sent means  of  observation  are  insufficient  to  enable  us 
to  detect.  It  may,  however,  be  doubted  whether  we 
shall  ever  be  able  to  discover  the  actual  anatomical  con- 
ditions of  those  innumerable  forms  of  perverted  function 
which  in  themselves  constitute  so  many  of  the  disorders 
of  every-day  life.  When  describing  the  condition  of 
any  organ,  and  still  more,  when  attempting  to  define  its 
range  and  modes  of  action,  we  must  often  be  puzzled 
to  determine  the  point  at  which  health  ends  and  disease 
begins.  In  the  state  of  every  part,  and  in  the  perfor- 
mance of  everv  function,  there  are  considerable  differ- 
ences  within  the  limits  of  health,  and  changes  which,  if 
permanent,  would  constitute  disease,  may  be  so  transient 
as  not  to  merit  such  a  designation.  In  the  case  of 
slight  and  temporary  nervous  disorders,  it  may  well  be 
imagined  that  there  is  a  dynamic  derangement  of  the 
nerve-centres,  or  some  change  in  their  Intimate  being  or 
mode  of  action,  without  any  recognized  alteration  of  the 
nervous  tissue.     It  may  easily  be  supposed  that,  under 


4      JEXCITABILITY  INCHJEASJED  OR  DIMINISHED. 

such  circumstances_,  a  piece  of  nervous  mechanism 
should  act  in  an  abnormal  manner_,  and  that  the  per- 
verted action  should  be  accompanied  by  other  signs  of 
disorder.  Excitability  is  the  common  property  of  alJ 
living  parts,  and  is  an  essential  condition  of  life.  It  is 
obviously  susceptible  of  considerable  variation  in  degree 
or  extent,  without  going  beyond  or  falling  short  of  the 
limits  of  health.  The  other  vital  endowments  of  the 
tissues,  e.g.,  the  assimilatory  property  and  sensibility, 
are  also  capable  of  similar  variations. 

Under  the  influence  of  various  causes,  the  excitability 
or  any  other  property  may  be  so  increased  or  diminished 
as  to  cause  uneasiness  to  the  individual  and  to  modify 
the  performance  of  the  functions  of  the  part  especially 
affected.  Such  a  condition,  if  of  brief  duration,  does 
not  necessarily  constitute  disease,  even  if  the  alteration 
in  the  function  appear  to' be  considerable.  This  state- 
ment may  be  illustrated  by  a  consideration  of  the  eflfects 
produced  by  heat  and  cold.  These  agents  often  cause 
either  increase  or  diminution  of  function  as  well  as  pain- 
ful impressions;  but  if  these  disappear  on  removal  of 
the  cause,  and  no  permanent  alteration  results,  the  con- 
dition which  was  temporarily  set  up  can  hardly  be 
regarded  as  one  of  disease. 


FUNCTIONAL  CARDIAC  DISORDER.  $ 

That  considerable  alteration  in  the  action  of  a  part 
may  occur  in  the  absence  of  structural  change  is  abun- 
dantly evidenced  in  the  case  of  the  heart ;  and  in  certain 
conditions    of   this    organ    we  have   the  most  striking 
examples  of  another  fact,  viz.,  that  functional  disorder 
long-continued  may  end  in  structural  lesion.     While  it 
is  true  that  cardiac  hypertrophy   most  often  proceeds 
from  increase  of  resistance  to  the  onward  flow  of  the 
blood,  cases  are  sometimes  seen  in  which  the  enlarge- 
ment is  a  result  of  increased  cardiac  action  without  any 
augmentation  of  resistance.     The  action  of  the  heart  is 
accelerated  by  excitement  of  all  kinds,  and  the  resultant 
phenomena  are  due  to  the  abnormal  activity  of  a  normal 
function.    As  Niemeyer  states, ''  in  many  persons  suffer- 
ing from  cardiac  hypertrophy  we  are  forced  to  assume 
the  existence  of  an  exalted  irritability,  an  erythism  of 
the  nervous  system,  particularly  of  the  nerves   of  the 
heart,    so    that    trifling    causes    serve    to    excite   and 
strengthen    its    action.''"'     In    cases  such  as   these   the 
increased  cardiac  action,  at  first  purely  functional,  sets 
up  after  long  continuance  a  decided  structural  change. 

It  is,  however,  in  connection  with  the  nervous  system 
that  the  large  majority  of  functional  disorders  are  found 
to    exist,    and    to    this    class    of    aflections    the   term 


6      IJPILEFSY  AN  EXAMPLE  OF  THE  NEUROSES. 

'^neurosis"  has  been  applied.  It  is  quite  true  that  in 
many  fatal  cases  of  these  disorders  structural  changes 
of  various  kinds  have  been  discovered,  but  the  relations 
which  such  changes  bear  to  the  symptoms  are  matters 
of  the  greatest  uncertainty.  The  great  variety  in  the 
alterations  as  regards  their  seat,  character,  and  intensity 
often  renders  it  impossible  to  connect  them  with  the 
symptoms  in  any  definite  manner.  Two  well-known 
nervous  disorders,  epilepsy  and  chorea,  furnish  abundant 
evidence  in  proof  of  this  statement.  With  regard  to 
epilepsy,  Dr.  Brown-Sequard  states  that  ^'  nothing  has 
resulted  froin  the  efforts  that  have  been  made  to  establish 
the  theory  that  epilepsy  depends  on  disease  in  any  part 
having  a  special  name  in  the  nervous  centres.  The  so- 
called  seat  of  epilepsy  has  been  successively  placed  in 
the  cerebellum,  the  cornu  Ammonis,  the  pons  Varolii, 
the  convolutions  of  the  brain,  etc.  There  is  just  as 
much  reason  to  place  that  seat  in  those  parts  as  there 
would  be  to  place  it  in  the  mucous  membrane  of  the 
bowels  or  the  sole  of  the  foot,  or  in  any  peripheric  part 
of  the  nervous  system  where  an  irritation  is  found  caus- 
ing epilepsy.  In  cases  such  as  these  last,  as  well  as  in 
the  preceding,  an  irritation  starts  from  the  place  where 
we  find  an  organic  lesion  and  proceeds  to  nerve-cells  in 


CHOREA  AN  EXAMPLE  OF  THE  NEUROSES.         7 

the  base  of  the  brain^  and  in  the  upper  part  of  the  cord, 
or  in  one  of  these  parts  alone.  Through  this  irritation 
those  nerve-cells  have  their  nutrition  altered,  and  after  a 
time  they  acquire  that  morbid  excitability  which  is  the 
essence  of  epilepsy.  We  do  not  think  it  will  ever  be 
possible  to  recognize  what  cells  are  altered,  as  it  is  quite 
likely  that  the  change  in  them  is  more  dynamical  than 
physical,  and  that  no  more  microscopic  differences  could 
be  detected  between  two  of  them,  one  normal  and  the 
other  possessing  great  morbid  reflex  power,  than  there 
are  visible  differences  between  two  pieces  of  magnet — 
one  poor,  the  other  rich  in  magnetic  power?'  It  is  of 
course  admitted  that  in  cases  of  epilepsy  lesions  are  often 
found  within  the  cranium  which  have  set  up  the  irrita- 
tion in  the  nervous  centres,  while  other  changes  are  the 
consequences  of  the  oft-repeated  paroxysms.  The  im- 
portant fact  remains  that  no  special  lesion  is  constantly 
present. 

The  pathogeny  of  chorea  is,  if  possible,  still  more 
obscure  than  that  of  epilepsy.  To  give  a  detailed 
account  of  the  various  theories  that  have  been  advanced, 
and  of  the  morbid  conditions  that  have  been  found  in 
connection  with  chorea,  would  be  beyond  the  scope  of 
this  chapter,  and  for  information  on  these  topics  the 


8         CSORJEA  AN  EXAMPLE  OF  THE  NEUROSES. 

reader  is  referred  to  subsequent  pages.  It  is  here  only 
necessary  to  mention  some  of  the  morbid  appearances 
that  have  been  described  in  order  to  show  the  difficulties 
of  reconciling  any  of  them  with  the  clinical  manifesta- 
tions of  the  disorder.  The  embolic  theory  of  chorea, 
first  advanced  in  1852  by  Dr.  Kirkes,  has  gained  much 
acceptance  of  late  years.  Before  that  date,  and  from 
the  early  part  of  this  century^  the  disorder  was  supposed 
to  be  closely  connected  with  rheumatism,  a  view  which 
was  further  supported  by  the  frequent  existence  of  a 
cardiac  murmur.  The  presence  of  warty  vegetations 
on  the  valves  of  the  heart,  so  commonly  found  in  fatal 
cases  of  chorea,  suggested  the  embolic  theory.  Dr. 
Hughlings  Jackson  thinks  that  '^  the  direct  pathological 
state  leading  to  instability  of  grey  matter,  producing 
choreal  movements,  is  increased  quantity  of  blood  in  the 
periphery  of  the  capillary  district  embolized."  The  main 
seat  of  such  lesions  is  fixed  in  the  corpus  striatum. 
Another  authority  on  chorea,  Dr.  Dickinson,  in  his 
examination  of  seven  fatal  cases  of  the  disorder  was 
unable  to  detect  any  signs  of  embolism.  On  the  other 
hand,  he  found  that  both  the  brain  and  spinal  cord  were 
affected,  and  that  the  changes  were  all  connected  with 
vascular   disturbance.     The    parts    of   the    brain    most 


CKOUBA  AN  EXAMPLE  OF  THE  NEUROSES.  9 

decidedly  implicated  were  those  lying  ^^  between  the  base 
and  the  floor  of  the  lateral  ventricles  in  the  track  of  the 
middle  cerebral  arteries ;  "  in  the  cord  no  region  was 
•exempt.  In  all  parts  the  first  visible  change  appeared 
to  be  "  injection  or  distension  of  the  arteries  succeeded 
by  extrusion  of  their  contents,  to  the  irritation  and 
injury  of  the  surrounding  tissue/^ 

It  is  unnecessary  to  refer  to  accounts  of  other  morbid 
appearances  discovered  in  fatal  cases  of  chorea,  for  with 
reference  to  all  of  them  it  may  t)e  stated  that  they  cannot 
be  presumed  to  underlie  even  severe  choreic  manifesta- 
tions which  come  on  suddenly,  and  quickly  disappear 
under  suitable  treatment.  With  regard  to  embolism,  it 
has  been  clearly  pointed  out  by  Dr.  Sturges,  in  his  excel- 
lent work  on  chorea,  that  this  process,  so  far  as  our 
knowledge  of  it  extends,  does  not  produce  symptoms 
similar  to  those  of  the  disorder  under  consideration. 
The  symptoms  of  cerebral  embolism  are  vertigo,  pain 
in  the  head,  faintness  or  sickness,  more  or  less  complete 
hemiplegia,  and  impairment  of  sensation  ;  the  course  of 
the  disease  is  usually  from  bad  to  worse,  recovery  is 
never  complete,  and  the  symptoms  characteristic  of  the 
•first  attack  are  apt  to  recur.  When  minute  arteries  are 
affected.  Dr.  Sturges  points  out  that  in  addition  "  there 


lo  CSOTITIA  A  FUNCTIONAL  BISORDER. 

is  often  active  delirium_,  high  temperature,  and  a  train  of 
symptoms,  rapidly  fatal,  which  resemble  most  specific 
fever.^^  It  is  almost  needless  to  say  that  symptoms 
such  as  these  offer  the  strongest  possible  contrast  to 
those  of  chorea.  Additional  evidence  against  the 
embolic  theory  is  supplied  by  the  fact  that  microscopic 
emboli  have  been  very  rarely  found  in  fatal  cases  of  the 
disease. 

The  anatomical  theories  of  chorea  being  thus  insuffi- 
cient to  account  for  the  symptoms,  we  may  ask,  with 
Dr.  Sturges,  whether  the  affection  may  not  "  be  looked 
upon  as  a  functional  disorder,  which  is  as  much  beyond 
the  reach  of  anatomical  demonstration  as  are  the  various 
passions  and  emotions  which,  like  it,  distort  and  coerce 
the  body  in  a  great  variety  of  ways  ?  "  There  is  much 
to  be  said  in  favour  of  this  view,  and  the  following  are 
the  principal  arguments  adduced  by  the  author  referred 
to.  The  limbs  are  affected  in  chorea  in  the  order  of' 
their  use  as  intelligent  instruments,  and  not  as  they 
would  upon  any  assumption  of  injury  or  irritation  of 
a  motor  centre.  The  untaught  muscles  and  those  that 
have  never  been  employed  as  agents  of  intelligence 
never  suffer  from  chorea,  while  the  more  complex  the 
muscular  employment,  the  greater  the  liability  to  suffer.. 


CHORJEA  A  FUNCTIONAL  DISORDEH.  ii 

There  is  therefore  in  chorea  the  withdrawal  or  impair- 
ment of  controlling  power  over  certain  parts  of  the 
frame  ;  the  education  of  the  muscles  concerned  is 
arrested  "  by  some  nervous  shock  which  renders  them 
useless  and  unruly^  while  the  operation  of  the  will^  no 
longer  sufficing  to  regulate  the  limbs_,  tends  rather  to 
disfigure  the  movements  it  seeks  to  arrest.'^  Chorea 
consists  of  an  exaggeration  of  those  muscular  move- 
ments which  are  constantly  taking  place,  and  especially 
in  children  who  have  not  as  yet  acquired  the  power  of 
governing  the  actions  of  their  muscles.  The  irregular 
movements  are  most  marked  in  the  face,  arms,  and 
hands,  for  the  muscles  of  those  parts  are  mainly 
employed  as  agents  of  intelligence,  and  when  the  con- 
trolling power  of  the  brain  or  higher  centres  is  lessened 
or  removed,  as  a  result  of  shock  or  otherwise,  fuller  play 
is  given  to  the  power  of  the  lower  centres.  The  mis- 
movements  are  but  an  exaggeration  of  those  which  are 
natural  to  the  age  of  the  child  ;  a  mere  restlessness 
devoid  of  character  or  rhythm.  '^^But  when  chorea 
comes  to  the  adult,  his  fixed  habits  of  moving  will 
impart  to  the  disorder  a  distinct  method ;  the  affected 
limbs,  that  is  to  say,  are  jerked  about  in  a  manner  that 
may  be  described."     As  additional  evidence  in  support 


12     CAUSES  OF  FUNCTIONAL  NERVOUS  DISORDERS. 


of  the  functional  hypothesis  of  chorea,  Dr.  Sturges 
refers  to  the  frequent  recurrence  of  the  symptoms  until 
adult  life  is  reached;  the  starting-place  of  the  move- 
mentSj  this  often  being  situated  in  those  muscles  most 
directly  beset  or  embarrassed,  and  to  the  most  common 
immediate  causes  of  the  disorder.  To  these  arguments 
may  be  added  the  fact  that  the  movements  are  some- 
times originated  as  a  result  of  imitation^  and  may  thus 
spread  through  a  school. 

Having  thus  endeavoured  to  show  that  functional  dis- 
order may  exist  in  the  absence  of  discoverable  change  of 
structure,  it  remains  to  consider  the  causes  and  general 
characters  of  functional  affections,  especially  of  those 
of  the  nervous  system.  The  discovery  of  the  cause  in 
a  case  of  this  nature  is  a  matter  of  the  highest  impor- 
tance_,  for  the  obvious  reason  that  it  constitutes  the  only 
safe  guide  to  a  rational  and  successful  treatment.  When 
structural  changes  have  taken  place,  the  discovery  of 
the  cause,  though  always  desirable,  is  less  likely  to  be 
followed  by  satisfactory  results. 

Hereditary  predisposition  plays  a  very  considerable 
part  in  the  causation  of  functional  nervous  disorders, 
and  aids  greatly  in  perpetuating  attacks  which  have  been 
excited  by  influences  of  the  most  diverse  kinds.     Thus, 


hi:  RED  IT  A  R  Y  PREDISP  OSITION.  ^  ^ 

to  take  chorea  again  as  an  example,  in  many  cases  its 
symptoms  are  obviously  caused  by  fright  or  mental 
excitement  which  they  immediately  follow.  Their  con- 
tinuance long  after  the  exciting  cause  has  disappeared 
must  be  due  to  some  peculiarity  in  the  nervous  organi- 
zation, and  in  children  thus  affected  with  chorea 
hereditary  predisposition  to  nervous  disorder  will 
generally  be  traceable.  Sometimes  the  same  disease  is 
handed  down  ;  in  other  instances  another  form  of  dis- 
order appears  in  the  descendants.  Epilepsy  is  thus 
often  transmitted  from  father  to  son,  and  this  feature  of 
the  disorder  is  very  clearly  exhibited  by  Dr.  Brown- 
Sequard's  experiments,  in  which  the  progeny  of  guinea- 
pigs  artificially  rendered  epileptic  suffered  in  the  same 
manner.  In  the  second  class  we  meet  with  examples 
such  as  this  :  an  epileptic  father  begets  a  son  who 
suffers  from  chorea,  and  one  or  more  children  of  the 
latter  display  symptoms  of  idiocy.  The  phenomena 
of  atavism  are  often  witnessed  in  connection  with 
nervous  disorders. 

Families  in  whom  histories  of  this  character  are  dis- 
coverable are  said  to  possess  a  neuropathic  predisposi- 
tion, that  is  to  say,  their  members  come  into  the  w^orld 
possessing  a  greater  or  less  tendency  towards  affections 


1 4     CAUSES  OF  FUNCTIONAL  NERVOUS  DISORDERS. 

of  the  nervous  system.  Wherein  such  a  tendency 
consists  is  a  question  that  cannot  be  answered  in  precise 
terms.  We  may  assume  an  abnormal  increase  of  irrita- 
biUty,  a  diminished  power  of  resisting  external  influences, 
or  lastly  excessive  elasticity  of  the  vascular  walls  and  a 
consequent  tendency  to  hypersemia. 

In  dealing  with  cases  of  nervous  disorder,  and 
especially  in  forming  a  prognosis,  it  is  a  matter  of  great 
importance  to  determine  whether  a  neuropathic  pre- 
disposition is  present  or  not.  To  establish  its  presence, 
it  is  not  indeed  necessary  to  discover  a  history  of  such 
typical  nervous  disorders  as  are  described  in  text-books ; 
evidence  of  marked  peculiarities  of  psychical  character 
may  be  all  that  is  forthcoming  and  may  yet  be  sufficient. 
Another  factor  of  considerable  importance  is  the  intensi- 
fication which  almost  any  kind  of  tendency  to  nervous 
disorder  derives  from  being  common  to  both  parents,  as 
measured  by  the  results  too  often  witnessed  from  the 
marriage  of  persons  nearly  related  to  each  other  and 
subject  to  the  same  taint.  The  influence  of  alcoholic 
excesses  on  the  part  of  one  or  both  parents  is  daily 
becoming  more  and  more  recognized  in  connection  with 
nervous  disorders  in  the  offspring.  It  is  also  highly 
probable  that  drunkenness  at  the  time  of  impregnation 


JSBUCATION  AND  EARLY  TRAINING.  15 

is  not  without  influence  on  the  nervous  system  of  the 
foetus. 

The  hereditary  constitution  is^  however^  liable  to  con- 
siderable modification  from  external  influences^  both 
such  as  directly  affect  the  physical  conditions  and  such 
as  act  through  the  consciousness.  In  the  latter  category 
the  roost  potent  factors  are  those  which  are  connected 
with  education.  The  influence  of  the  early  training 
upon  the  causation  of  nervous  disorder  on  the  one  hand^ 
and  upon  its  prevention  on  the  other_,  can  scarcely  be 
over-estimated.  One  point  deserves  special  attention. 
The  first  thing  that  a  child  ought  to  learn  is  to  obey ; 
for  if  this  lesson  be  neglected  the  power  of  self-govern- 
ment is  likely  never  to  be  acquiredj  and  the  passions 
will  remain  unchecked.  The  vaso-motor  system  of 
nerves  is  highly  excitable  in  childhood,  and  the  indul- 
gence of  every  unchecked  passion  causes  hypersemia  of 
the  brain  and  distension  of  the  cerebral  vessels.  Fre- 
quent repetition  leads  to  paresis  of  the  muscular  coat 
of  the  vessels  and  more  or  less  permanent  dilatation. 
Results  of  this  character  are  often  due  to  continuous 
mental  strain  and  to  sexual  excesses.  In  the  course  of 
time  another  factor  comes  into  play.  The  inhibitory 
centres  in  the  brain,  from  w^ant  of  exercise^  lose  their 


•I 6    CAUSES  OF  FUNCTIONAL   NERVOUS  DISORDERS. 

functional  capacity^  so  that  a  very  slight  cause  suffices. 
to  induce  cerebral  hyperaemia,  which  at  last  becomes 
habitual. 

With  reference  to  physical  and  mental  causes  of 
nervous  disorders_,  I  venture  to  quote  what  I  have  else- 
where written  on  this  subject.  "Every  age  is  charac- 
terized by  the  presence  or  prevalence  of  special  disorders 
of  health,  which  have  a  more  or  less  obvious  causation. 
At  the  present  day  '  want  of  tone'  is  the  characteristic 
feature  of  disorders  in  general,  and  in  none  is  it  more 
obvious  than  in  those  which  peculiarly  affect  official  and 
professional  men  working  at  high  pressure.  As  might 
be  expected,  the  signs  of  this  want  of  tone,  or  weakness 
of  the  nervous  system,  vary  in  different  persons,"  but 
the  condition  itself  is  mainly  due  to  excessive  wear  and 
tear  of  body  and  mind.  At  the  present  day  almost 
everything  has  to  be  done  at  high  pressure;  we  strive 
to  emulate  the  rapidity  of  the  telegraph  and  the  steam 
engine.  "  Incessant  struggles  to  get  on,  trampling, 
crushing,  elbowing,  and  treading  on  each  other's  heels, 
are  manifest  symptoms  of  the  present  phase  of  indus- 
trial progress.  Even  in  our  recreations  there  are  evi- 
dences of  a  similar  spirit."  Thus  ith>  -•  ns  that  man- 
of   our    contemporaries  fall   out  of  the  race  with  only 


CA  USES  OF  FUNCTIONAL  NEE  VO  US  DISORDERS.    1 7 

shattered  nerves  and  weakened  bodies  as  results  of  their 
ill-regulated  efforts.  Over-strain  of  the  heart  is  another 
modern  disorder  traceable  to  the  same  causes_,  and  this 
is  due  to  mental  as  well  as  to  bodily  over-exertion.  The 
influence  of  sexual  excesses  in  producing  and  perpetua- 
ting nervous  disorders^  and  in  lowering  the  tone  of  the 
system^  can  scarcely  be  over-estimated. 

The  immoderate  use  of  stimulants  is  another  fertile 
cause  of  nervous  disorders,  and  it  greatly  aids  the  opera- 
tion of  other  factors.  Alcohol,  tobacco,  coffee,  and  tea  are 
often  taken  in  excess  in  order  to  enable  a  man  to  con- 
tinue the  struggle.  These  agents  stimulate  the  nervous 
system  and  enable  it  to  get  through  an  abnormal  amount 
of  work,  but  as  excitement  is  necessarily  followed  by 
debility  the  total  result  of  the  repeated  stimulations  is 
simply  a  lessening  of  power.  With  regard  to  other 
agents,  such  as  morphine  and  chloroform,  which  are 
used  to  deaden  sensibility  and  to  drown  care,  there  is, 
unfortunately,  too  much  reason  to  believe  that  their 
employment  is  becoming  more  and  more  common. 

We  are  often  inclined  to  attribute  nervous  disorders 
to  the  operation  of  cold,  and  sometimes  for  the  reason 
*hat  no  other  c  'i«^'^,  is  sufficiently  obvious.  As  a  matter 
oi  tact,  there  is  a  close  connection  between  exposure  to 

2, 


1 8    CA  USES  OF  FUNCTIONAL  NFE  VO  US  BISORDFRS. 

cold  and  certain  nervous  affections,  but  the  statements 
of  patients  on  this  point  should  always  be  carefully 
sifted.  There  is  no  doubt  that  neuralgia  is  often  pro- 
voked by  exposure  to  draughts  of  air^  and  that  the  most 
common  form  of  facial  paralysis  owns  a  similar  causa- 
tion. 

In  our  endeavours  to  discover  the  cause  of  functional 
nervous  disorder  we  must  not  forget  the  influence  of 
irritation  conducted  from  distant  parts^  and  of  patho- 
logical changes  in  other  organs.  It  is  only  in  com- 
paratively recent  times  that  we  have  learnt  to  recognize 
the  fact  that  injuries  of  peripheral  nerves  may  set  up 
changes,  probably  of  an  inflammatory  character,  which 
extend  to  the  central  organs  and  cause  serious  lesions. 
In  persons  with  a  neuropathic  predisposition_,  e.g.,  to 
epilepsy,  very  slight  injuries  may  suffice  to  produce 
paroxysms.  In  a  similar  manner  pathological  irritation 
of  peripheral  portions  of  the  nervous  system,  and  par- 
ticularly such  irritation  as  is  liable  to  occur  in  the 
digestive  and  sexual  organs,  not  unfrequently  gives  rise 
to,  and  invariably  exaggerates,  many  nervous  affections ; 
for  example,  hysteria  and  hypochondriasis.  Not  only 
changes  in  distant  organs,  but  changes  in  the  blood 
itself  may  be  the  cause  of  nervous  affections ;  it  is  only 


CA  US:ES  of  functional  NER  VO  us  disorders.    19 

necessary  to  mention  the  common  effects  of  anaemia  and 
of  various  exhausting  diseases  as  examples  of  this  kind. 
Nem'algic  affections  are  often  the  results  of  exposure  to 
malarious  influences^  and  according  to  the  statements  of 
some  writers  are  closely  associated  with  that  condition 
of  system  which  predisposes  to  pulmonary  consump- 
tion. 

Among  blood-poisons  affecting  the  nervous-system, 
syphilis  occupies  a  very  prominent  place.  Its  morbid 
products  are  liable  to  be  deposited  in  the  brain_,  spinal 
cord,  and  peripheral  nerves ;  such  deposit  may  give  rise 
to  symptoms  of  the  most  severe  type,  and  these  may 
not  show  themselves  until  many  years  have  elapsed 
since  infection.  The  possibility  of  syphilis  being  at  the 
root  of  a  given  nervous  disorder  should  always  be  borne 
in  mind.  Many  cases  with  a  syphilitic  history  are 
more  amenable  to  treatment,  and  admit  of  a  more 
favourable  prognosis  than  others  in  which  no  such  taint 
can  be  traced.  The  gouty  diathesis  is  another,  and  a 
potent  cause  of  nervous  disorders ;  in  fact,  the  term 
*'  nervous  gout "  has  been  applied  to  the  entire  class  of 
irregular  gouty  manifestations.  ^*^  Nervous  affections  of 
this  character  occur  especially  in  women,  and  in 
individuals    generally  of  a  nervous    temperament   and 


20    CA  USES  OF  FUNCTIONAL  NFR  VO  US  DISORDERS. 

descended  from  gouty  ancestors.  In  some  families  the 
male  members  a.re  the  victims  of  acute  gout_,  while  the 
females  suffer  from  neuralgia  in  various  forms^  head- 
ache/' &c.  Facial  neuralgia,  hemicrania_,  and  sciatica 
sometimes  alternate  with  attacks  of  articular  gout,  and 
such  grave  nervous  disorders  as  epilepsy  and  insanity 
are,  in  not  a  few  cases,  of  gouty  origin.* 

Reflex  irritation  has  been  already  alluded  to  as  a  cause 
of  nervous  disorders,  and  Dr.  Stevens,  of  New  York, 
has   endeavoured  to    show   that    the    neuropathic    pre- 
disposition may  consist  simply  of  a  local  irritation  due 
to    '^some   peculiarity    of  anatomical    structure    or   of 
physiological  adaptations,    which   is  inconsistent  with 
the  most  regular  and  easy  performance  of  the  function 
of  a  part  or  parts."     As  a  frequent  cause  of  physiological 
disturbance,  Dr.  Stevens  refers  to  the  difficulties  often 
attending    the    functions     of    accommodating   and    of 
adjusting  the   eyes  in  the  act  of  vision,  or  irritations 
arising  from  the  nerves  involved  in  these  processes.     A 
single  condition,  viz.,  hypermetropia,  may  be  selected  as 
an  example.     The  continued  and  unnatural  tension  of 


*  For  further  details  on  the  connection  between  gout  and  disorders  of 
the  nervous  system  the  reader  is  referred  to  my  work  on  "  Gout  and  its 
Helations  to  Diseases  of  the  Liver  and  Kidneys,"  Chapter  V. 


CA  USES  OF  FUNCTIONAL  NER  VO  US  BISORDFRS.    2 1 

the  ciliary  muscle  becomes  at  length  a  source  of  much 
weariness^  and  the  hypermetropic  eye  is  never  at  rest 
except  when  closed.  There  is  also  another  and  a  greater 
difficulty  connected  with  this  condition  of  the  eyes.  For 
perfect  vision  "  the  degree  of  accommodation  of  the  eyes 
singly  and  of  the  convergence  of  the  optic  axes  must 
be  in  harmony.  For  if  the  accommodation  be  fixed  for 
one  point  while  the  convergence  is  for  a  point  of  greater 
or  less  proximity^  there  must  result  an  absence  of  perfect 
definition^  or  the  presence  of  double  images.  A  pair  of 
normal  eyes  accommodated  for  a  given  distance  will 
converge  for  the  same  distance."  In  the  hypermetropic 
eye^  "  continual  compromising  adjustments  must  be 
made  and  great  nervous  perplexity  and  disappointed 
nervous  action  must  occur,  for  no  sooner  is  one  part  of 
the  adjustment  corrected  than  the  other  is  wrong."  The 
sensations  of  pain  and  weariness  characteristic  of 
hypermetropia  are  due  to  the  nervous  perplexity  even 
more  than  to  the  actual  strain  of  the  muscles;  and  Dr. 
Stevens  cites  many  instances  to  prove  that  this  condition 
of  things  continued  through  many  years  may  constitute 
a  permanent  source  of  nervous  irritation.  Astigmatism 
and  myopia  are  other  causes  of  nervous  perplexity  and 
n'ritation,  and  the  practical  value  of  this  theory  of  many 


22  FUNCTIONAL  NERVOUS  DISORDERS. 

forms  of  nervous  disorder  is  substantiated  by  the  good 
results  obtained  from  correcting  the  ocular  defects 
by  means  of  glasses.  Dr.  Stevens  cites  cases  of 
neuralgia,  migraine^  chorea,,  and  epilepsy  in  which  the 
patients  exhibited  ocular  defects  of  the  kinds  just 
described.  Ordinary  treatment  proved  of  little  or  no 
avail ;  but  in  many  of  the  cases  considerable  relief  or 
even  a  complete  cure  resulted  from  attention  to  the  eyes 
and  removal  of  ocular  disturbances.  Further  reference 
to  ocular  defects  as  a  cause  of  nervous  disorders  will  be 
found  in  subsequent  chapters. 

A  few  general  remarks  on  the  characters  of  functional 
nervous  disorders^  as  distinguished  from  those  of  organic 
origin,  will  conclude  this  part  of  my  subject. 

Functional  nervous  disorders  occur  in  all  conditions 
of  the  general  health,  though  many  of  them  are 
especially  associated  with  debility  ;  there  are  great 
variations  in  the  intensity  of  the  symptoms  ;  the 
attacks  are  wont  to  recurat  regular  or  irregular  intervals, 
during  which  the  health  is  often  perfectly  good.  In 
organic  disorders  the  principal  symptoms  remain  per- 
manent, and  variations  in  their  intensity  are  slowly 
developed.  A  sudden  improvement,  or  even  a  rapid  cure, 
is  not  unfrequent  in  functional  disorders;  such  changes 


FUXCTIOXAL  NEBVOUS  BISOHBERS.  23 

are  exceedingly  rare  in  organic  diseases  of  the  nervous 
system.  These  latter  are  often  accompanied  by  certain 
symptoms  of  irritation  of  conductors  of  sensitive 
impressions  and  of  trophic  and  secretory  nerve  fibres, 
as  evinced  by  various  abnormal  sensations  and  altera- 
tions of  nutrition  and  secretion  of  the  skin  and  mucous 
membranes.  In  functional  nervous  disorders,  with  the 
exception  of  some  forms  of  neuralgia,  these  changes 
are  of  rare  occurrence.  Such  general  features  as  pain, 
spasm,  and  local  paralyses  may  be  very  severe,  but,  if 
organic  disease  can  be  excluded,  they  rarely  cause  much 
anxiety  as  to  the  ultimate  issue.  Save  in  hysterical 
cases,  the  bladder  and  rectum  are  very  rarely  involved 
in  functional  nervous  disorders,  and  even  in  hysterical 
paraplegia  the  functions  of  these  organs  may  be 
normally  discharged.  The  application  of  electricity 
sometimes  enables  us  to  distinguish  between  functional 
and  organic  disease ;  the  use  of  this  agent  will  be 
described  in  the  remarks  on  the  diagnosis  of  the  special 
disorders. 


SECTION  I. 

FUNGTIOISIAL    DISORDERS  OF  THE  NERVOUS 

SYSTEM,   ■ 


CHAPTER    L 

NERVE     PROSTRATION— NEURASTHENIA— NERVOUS 
DEBILITY. 


Nerve  Prostration — Synonyms  and  meaning  of  Term — Nature  and 
Varieties — Prevalence  of  Nerve-prostration  in  England 
AND  IN  the  United  States — Causes — Dr.  BeXrd's  Views — 
Hereditary  Predisposition— Training  and  Habits  of  Young 
Subjects  —  Influence  of  Schoolwork  and  Competitive 
Examinations — Symptoms  of  Neurasthenia — Symptoms  con- 
nected with  the  Motor  Faculties — Disorders  of  the  Sen- 
sory Faculties  —  Spinal  Pain — Neuralgia  —  Disorders  of 
Special  Senses — Vaso-motor  Disturbances — Disorders  of 
THE  Circulatory,  Respiratory,  and  Digestive  Organs — 
Symptoms  referable  to  the  Kidney's  and  the  Organs  of 
Generation — Signs  of  Mental  Disorder — Disorders  of 
Sleep — Duration  of  the  Symptoms  of  Neurasthenia — Prog- 
nosis and  DiAGNiJSis — Treatment — Relief  of  the  Sleepless- 
ness—  Freedom  from  Mental  Exertion — Ajiusements  and 
Exercise — Diet — Avoidance  of  Tobacco  and  Excess  in 
Stimulants — Tonics    and  Bathing — Electricity — The  Weir- 


26  F0R2IS  OF  NFRVE  PROSTRATION. 

IMiTCHELL  System  —  Rest,  Isolation,  Excessive  Feeding,. 
Massage,  and  Employment  of  Electricity — Cases  in  which 
Indicated — Details  of  Treatment— Duration  of  Treatment 
AND  Results,  with  Illustrative  Cases — Cautions  as  to 
Adoption  of  Treatment  in  Cases  of  Organic  Disease  and 
OF  Mental  Disorder. 

Neurasthenia  or  nerve-prostration  is  a  constitutional 
neurosis^  affecting  the  whole  system.  The  term  has 
many  other  synonyms,  e.g.,  nervousness^  nervous 
debiHty,  nervous  exhaustion,  spinal  irritation,  &c.  It 
denotes  a  condition  in  which  weakness  of  the  nervous 
apparatus  is  associated  with  undue  irritability ;  excite^ 
ment  and  fatigue  are  produced  by  causes  which  in  a 
normal  state  of  things  would  not  be  followed  by  these 
effects.  In  one  series  of  cases  the  manifestations  of 
irritability  and  weakness  appear  mainly  in  the  action  of 
the  cerebral  centres,  and  we  refer  them  to  functional 
disorder  of  the  brain.  In  another  series  the  spinal  cord 
appears  to  be  mainly  implicated;  and  there  is  yet  a 
third  class  in  which  the  symptoms  indicate  disorder  in 
both  these  2;reat  nervous  centres.  Nothing;  is  known 
as  to  the  anatomical  changes,  if  any,  which  underlie 
the  symptoms.  These  latter  are  by  no  means  of  modern 
origination ;  but  under  the  various  influences  of  our 
nineteenth  century  civilization  they  have  become  very 


CA  USJES  OF  NER  VU  PR  OS  TRA  TION.  2  7 

common^  and  in  not  a  few  cases  very  serious.  Here^ 
in  England^  and  especially  in  our  large  cities,  instances 
daily  come  to  the  knowledge  of  the  physician  ;  but  it 
would  seem  that  for  frequency  of  occurrence  and 
severity  of  type  the  United  States  at  present  enjoy  an 
unenviable  reputation.  One  of  their  physicians^  Dr.  G. 
M.  Beard,  has  given  us  an  exhaustive  description, 
drawn  from  his  great  experience,  of  this  complaint. 

With  regard  to  the  causes  of  neurasthenia,  it  may  be 
stated  that  they  are"  those  of  nervous  depression  in 
general.  Dr.  Beard  asserts  that  the  inhabitants  of  the 
United  States  are  the  most  nervous  people  in  the  w^orld. 
In  order  to  exhibit  in  a  graphic  manner  the  causes  of 
American  nervousness,  he  makes  use  of  the  following 
algebraical  formula:  —  Civilization  in  general  +  Ameri- 
can civilization  (a  young  and  rapidly  growing  nation 
with  religious,  municipal,  and  social  freedom)  +  an 
exhausting  climate  (the  extremes  of  heat,  cold,  and 
dryness)  +  a  nervous  diathesis  (the  result  of  the  above- 
mentioned  factors)  +  immoderate  mental  and  bodily 
exertion,  or  excessive  proneness  to  be  swayed  by  in- 
clinations and  passions  =  neurasthenia  or  nervous 
exhaustion.  Similar  causes  are  common  enough  in 
England,  and  especially  in  the  large  cities;  probably 


28  CAUSES  OF  NERVE  PROSTRATION. 

London  contains  as  many  instances  of  neurasthenia  as 
any  American  city.  The  excitement  connected  with 
politics^  business,  Stock  Exchange  speculation,  and 
various  forms  of  gambling  is  nowhere  more  intense, 
and  is  daily  becoming  more  and  more  widely  spread. 
'^Wear  and  tear^^  are  in  excess,  while  ^' rest  and 
repair"  are  becoming  more  and  more  difficult. 

We  can,  therefore,  sum  up  all  that  can  be  said  as  to 
the  causes  of  neurasthenia  by  stating  that  they  are  in  the 
main  as  follows  : — Severe  and  prolonged  excitement  and 
mental  strain  ;  an  insufficient  amount  of  rest  and  sleep, 
often  coupled  with  improper  and  insufficient  food  ; 
excesses  of  all  kinds,  and  especially  indulgence  in  alcohol 
.and  tobacco.  The  patients  are  often  of  a  nervous  tem- 
perament, and  are  the  subjects  of  hereditary  pre- 
disposition to  nervous  disorder,  and  this  latter  is  one 
of  the  most  powerful  factors  in  the  production  of  neu- 
rasthenia. In  persons  with  a  family  history  of  diseases 
of  the  nervous  system  the  condition  most  often  noticed 
is  one  of  undue  liability  to  disturbance,  which  may 
show  itself  in  several  forms.  If  among  the  ancestors 
of  a  given  patient  there  have  been  instances  of  epilepsy, 
hysteria,  insanity,  tendency  to  excess  in  alcohol,  and 
the  like,  the  result  may  be  the  development  of  any  of 


CA  USES  OF  NER  VE  PR  OSTRA  TION.  29 

these  malaclies_,  and  not  at  all  necessarily  a  reproduction 
of  the  original  disorder.  In  all  cases  of  neurasthenia 
inquiry  should  be  made  as  to  the  existence  of  any 
morbid  tendency. 

There  can  be  no  doubt  as  to  the  influence  of  the 
training  and  habits  of  young  people  upon  the  production 
of  neurasthenia,  and  especially  in  those  cases  in  which 
there  is  any  hereditary  tendency  to  nervous  disorder. 
Such  a  tendency  often  shows  itself  in  very  early  life, 
and  such  children  are  of  poor  muscular  development, 
easily  excited  and  soon  fatigued,  unstable  in  their  wishes 
and  inclinations,  apt  to  sleep  badly,  not  unfrequently 
subject  to  night-terrors,  and  peculiarly  liable  to  convul- 
sions and  delirium  upon  the  supervention  of  any  febrile 
disorder.  They  are,  however,  generally  precocious, 
able  to  outstrip  their  contemporaries,  and  learn  easily  ; 
some  of  them,  thus  early  in  life,  show  signs  of  moral 
insanity  in  a  mild  form.  Lying,  stealing,  cruelty  to 
other  children  and  to  animals,  marked  insubordination 
and  various  acts  of  mischief  appear  to  have  special 
attractions  for  such  children,  and  to  mark  them  out  as 
peculiar.  These  tendencies  may  be  subdued  by  proper 
discipline  and  treatment ;  but,  if  neglected,  they  result 
not  only  in  fixed  habits,  but  in  other  serious  perversions 


30  CAUSES  OF  NERVE  PROSTRATION. 

of  the  moral  faculties.  I  have  recently  had  under  my 
care  a  young  lady,  aged  17,  whose  father  became 
insane  from  overwork.  After  considerable  nervous 
prostration,  lasting  for  some  weeks,  marked  sym- 
ptoms of  hysteria  and  melancholia  became  developed. 
Much  improvement  has  taken  place  under  the  influence 
of  kindly  discipline,  cheerful  society,  good  food,  and 
tonics. 

In  not  a  few  cases  school-work  is  potent  for  evil  in 
the  development  of  neurasthenia  among  the  young.  It 
is  only  necessary  to  point  to  the  struggles  engendered 
by  the  competition  everywhere  in  vogue  at  the  present 
time  j  to  the  so-called  "  cramming  "  with  all  its  unwhole- 
some accessories,  and  to  the  anxiety,  loss  of  sleep,  and 
disappointment  which  are  so  often  superadded  to  the 
results  of  extraordinary  efforts.  The  prevalence  of 
headache  and  of  disorders  of  vision  among  the  young 
of  both  sexes  is  a  measure  of  the  evil  which  is  growing 
up  in  our  midst.  I  have  seen  several  cases,  in  both 
sexes,  in  which  neurasthenia  was  purely  the  result  of 
over-fatigue  engendered  by  competitive  examinations  at 
school.  We  are  also  told  that  In  America  the  "social 
engagements "  of  the  pupils  add  not  a  little  to  the 
pressure  imposed  upon  them  by  their  studies. 


SYMPTOMS  OF  NEURASTHENIA.  31 

The  prominent  symptoms  of  neurasthenia  usually 
•show  themselves  in  early  middle-age ;  by  that  time  the 
various  causes  have  generally  been  at  work  long  enough 
to  produce  their  effect.  Much^  of  course,  depends  upon 
the  constitution,  habits,  and  surroundings  of  the  indi- 
vidual. The  accession  of  the  symptoms  is  liable  to  be 
hastened  by  the  outbreak  of  some  febrile  or  other  dis- 
order which,  even  in  fairly  vigorous  persons,  is  wont  to 
leave  a  condition  of  debility  in  its  train. 

Symptoms  connected  with  the  motor  faculties.  These 
are  often  the  first  to  appear,  and  may  exist  alone  for 
some  time.  The  most  prominent  symptom  is  muscular 
debility,  indicative  of  weakness  and  exhaustion  of  the 
nervous  system.  Such  patients  are  apt  to  feel  tired 
even  on  rising  from  their  beds,  and  a  feeling  of  pain  in 
the  legs  is  often  superadded  to  that  of  languor.  These 
sensations  are  aggravated  by  exercise ;  a  painful  feeling 
of  fatigue  is  easily  induced.  Some  patients  find  that 
even  the  effort  involved  in  writing  a  few  lines  causes 
more  or  less  discomfort,  and  that  this  feelino-  becomes 
so  marked  that  perseverance  is  all  but  impossible. 
Others  find  that  a  painful  sense  of  fatigue  comes  on 
after  a  short  walk,  and  that  aching  and  stiffness  in  the 
limbs,  lasting  perhaps  for  several  days,  are  the  penalty 


32  S  YMF  TOMS  OF  NF  UMA  STEJENIA . 

for  the  slightest  degree  of  over-exertion.  The  weakness 
of  the  museles  is  often  still  more  elearly  demonstrated 
by  uncertainty  of  their  action^  less  frequently  by 
tremulous  movements_,  and,  in  exceptional  cases,  by 
true  paralyses.  Convulsive  twitchings  of  muscles  and  of 
muscular  fibres  are  not  unfrequent  in  the  subjects  of 
neurasthenia  ;  and  chorea-like  movements  are  often 
noticed  in  the  muscles  of  the  face,  and  especially  in 
those  about  the  mouth.  The  face  is  seldom  at  rest,, 
and  a  proneness  to  laugh  is  occasionally  observed. 
Some  of  these  patients  complain  of  painful  cramps 
in  the  legs  at  night.  Palpitation  of  the  heart  is  very 
common. 

A  case  presenting  several  of  the  features  just  described 
has  recently  come  under  my  notice.  I  was  called  in  hj 
a  medical  friend  to  see  a  gentleman  aged  forty-four^  in 
whom,  after  a  long  period  of  anxiety,  very  marked  and 
troublesome  symptoms  of  neurasthenia  had  become 
developed.  There  was  considerable  mental  depression,, 
and  muscular  action  was  perverted  and  uncertain.  On 
starting  to  walk,  a  few  steps  would  be  correctly  made; 
then  the  movements  would  become  tremulous  and  the 
muscles  of  the  legs  would  twitch  so  violently  that  the 
patient    fell    unless    means    of   support  were  at  hand. 


SYMPTOMS  OF  NHURASTHENIA.  S3 

These  attacks  were  wont  speedily  to  pass  off  and  to  be 
followed  by  convulsive  twitchings  of  the  muscles  of  the 
face. 

The  disorder  of  the  sensory  faculties  shows  itself 
in  hypersesthesia  and  various  other  forms  of  disordered 
sensation  indicative  of  excessive  irritability  of  the 
sensory  nerves  and  nerve-centres.  Hyperaesthetic  spots 
can  often  be  detected  on  various  parts  of  the  body^ 
and  the  skin  is  more  sensitive  than  usual  to  contact 
with  hot  and  cold  water  and  solid  substances  in  general. 
I  have  seen  several  cases  in  whom  these  disorders  of 
sensation  were  well  marked.  In  the  case  of  a  lady  who 
had  had  several  children  in  quick  succession  there  was 
acute  suffering  from  tender  spots  or  points  in  the 
intercostal  and  lumbar  regions^  and  the  skin  of  the 
chest  and  back  would  occasionally  become  so  tender 
that  contact  with  her  silk  vest  proved  almost  unbear- 
able. Such  patients  often  experience  actual  pain, 
especially  in  the  head  and  back  and  along  the  spine. 
Pain  in  this  last-mentioned  situation,  both  spontaneous 
and  excited  by  pressure,  is  the  predominant  symptom 
in  "spinal  irritation/^  a  form  of  neurasthenia,  which 
will  be  described  in  a  subsequent  chapter,  though  for 
the  sake  of  completeness  its  prominent  features  will 
now  be  mentioned.     The  pain  is  most  often  confined  to 

3 


34  SYMPTOMS  OF  NEURASTHENIA. 

a  certain  spot ;  but  it  may  be  diffused  over  the  spine. 
It  is  aggravated  by  pressure  and  by  pinching  up  the 
skin,  and  by  movements  of  various  kinds.  When  the 
cervical  region  is  affected  the  seventh  spinous  process  is 
generally  the  most  sensitive.  When  the  pain  is  felt  in 
the  dorsal  vertebrae  there  are  often  attacks  of  difficulty 
of  breathing,  which  are  also  liable  to  be  induced  when 
pressure  is  made  over  the  painful  spot.  In  some  cases 
not  only  pain,  but  nausea  and  faintness  are  caused  by 
pressure  over  one  or  more  vertebrae.  The  pain  is  some- 
times felt  low  down  in  the  lumbar  and  sacral  regions, 
and  is  then  much  increased  by  walking  and  standing. 
In  all  cases  the  pain  is  apt  to  change  its  place,  and  may 
disappear  from  time  to  time. 

Various  forms  of  neuralgia  are  apt  to  occur  in  neuras- 
thenic patients,  the  pain  being  remarkably  obstinate  and 
simulating  that  due  to  serious  disorder  of  the  nervous 
centres.  In  some  of  these  patients  the  pain  is  of  a 
migratory  character,  and  in  the  course  of  time  affects 
most  of  the  regions  of  the  body.  Other  forms  of 
disordered  sensation  are  not  uncommon,  e.g.,  chilliness, 
a  feeling  as  if  cold  water  were  running  down  the  back, 
numbness  of  the  legs  and  arms,  tingling  and  itching  in 
various  parts,  especially  about  the  genital  organs. 

Signs  of  disorder  of  the  organs  of  special  sense  are- 


SYMPTOMS  OF  NEURASTHENIA. 


35 


noticed  in  some  cases.  A  peculiarly  dull  look  is 
associated  with  redness  of  the  conjunctivae,  due  to  sleep- 
lessness. The  pupils  are  dilated,  but  move  freely; 
sometimes  inequality  is  noticed.  Intolerance  of  light, 
exposure  to  which  causes  headache,  weakness  of  vision, 
and  muscae  volitantes  and  flashes  of  light  before  the 
eyes  are  not  uncommon.  Hearing  is  sometimes  preter- 
naturally  acute,  and  subjective  sensations  of  buzzing, 
ringing  or  pulsations  in  the  ears  are  frequently  experi- 
enced. The  rushing  sound  of  the  blood  during  in- 
creased cardiac  action  is  very  troublesome  and  alarm- 
ing to  some  of  these  patients.  Giddiness  is  a  common 
symptom. 

Symptoms  indicative  of  vaso-motor  disorder  are  of 
constant  occurrence  in  the  subjects  of  neurasthenia. 
Many  of  them  are  annoyed  by  the  blushes  which  are 
involuntarily  provoked  on  the  slightest  occasions.  On 
the  other  hand,  some  of  these  patients  become  pale  and 
faint  when  excited  or  alarmed  ;  and  even  when  the  head 
and  face  are  hot,  the  hands  and  feet  are  apt  to  be  cold 
and  clammy.  I  am  now  attending  a  gentleman  full  of 
courage  and  energy  and  yet  liable  to  outbreaks  of  cold, 
clammy  perspiration  during  important  interviews  and 
even  on  the  receipt  of  a  letter  containing  unexpected 
intelligence.     Other  symptoms  belonging  to  this  class 


36  SYMPTOMS  OF  NEURASTHENIA. 

are  indicative  of  disordered  action  of  the  heart,  and 
these  are  wont  to  supervene  very  suddenly  and  to  excite 
much  anxiety.  The  slightest  mental  or  bodily  exertion 
causes  a  great  increase  in  the  frequency  of  the  pulse 
with  distressing  palpitation  as  a  frequent  accompani- 
ment. The  rushing  of  blood  to  the  head  and  the 
throbbing  of  the  vessels  in  the  neck  are  much  dreaded 
by  the  patient.  Abdominal  pulsation  is  not  unfrequent, 
and  a  similar  sensation  is  sometimes  experienced  over 
the  greater  part  of  the  body.  Further  reference  will  be 
made  to  the  cardiac  symptoms  in  the  chapters  on 
neuroses  of  the  heart. 

The  organs  of  respiration  are  less  commonly  affected, 
hut  they  sometimes  exhibit  manifest  evidences  of  dis- 
ordered function.  There  are  certain  changes  in  the 
voice  which  Dr.  Beard  regards  as  characteristic;  words 
are  pronounced  in  a  low  tone  and  hesitating  manner ; 
any  special  effort  to  express  thoughts  causes  dryness  of 
the  mouth  and  throaty  and  this  in  its  turn  renders 
speaking  impossible.  Nervous  cough  is  another 
symptom  of  this  character,  and  one  which  annoys  and 
alarms  the  patient.  It  is  apt  to  be  very  troublesome  at 
night,  and  the  loss  of  rest  thus  caused  tends  still  further 
to   reduce   the    strength.      In  such  cases  a  suspicion 


SYMPTOMS  OF  NEURASTHENIA.  37 

of  consumption  is  often  excited.  In  a  case  of  this 
kindj  occurring  in  a  young  lady,  an  intractable  cough 
had  been  very  frequent  at  intervals  during  two  years.  It 
was  undoubtedly  due  to  nervous  irritation,  and  dis- 
appeared after  a  few  days'  treatment  with  quinine, 
bromide  of  potassium,  and  hydrobromic  acid.  A  desire 
for  air  is  sometimes  noticed  in  these  patients.  When 
indoors  they  complain  of  a  feeling  as  though  they  were 
being  stifled,  and  sit  before  an  open  window  in  order  to 
obtain  relief. 

Disorders  of  the  digestive  oro;ans  are  very  common 
in  neurasthenic  subjects,  and  occur  in  various  forms. 
Indigestion  is  sometimes  the  first  symptom,  and  its 
manifestations  are  almost  endless  in  number.  Loss  of 
appetite,  pain,  and  a  sensation  of  fulness  in  the  epi- 
gastrium, eructations,  vomiting,  flatulent  distension, 
obstinate  constipation,  alternating  with  diarrhoea,  in 
which  the  food  passes  through  the  bowels  but  slightly 
changed,  are  the  most  prominent  symptoms  referable  to 
the  stomach  and  bowels.  Nervous  dyspepsia  is  charac- 
terized by  its  sudden  appearance  and  rapid  subsidence ; 
by  its  alternating  with  other  nervous  symptoms,  and  by 
the  relief  afforded  by  sedatives  and  by  articles  of  food 
which  would  increase  the  symptoms  of  gastric  catarrh. 


38  SYMPTOMS  OF  NEURASTHENIA. 

It  is  a  remarkable  fact  that  in  some  cases  of  this  kind 
the  appearance  of  the  patients  is  that  of  good  health, 
and  their  nutrition  seems  to  be  unaffected.  In  another 
class  the  evidences  of  ill-health  are  unmistakable,  in 
spite  of  a  fair  appetite  and  a  good  supply  of  nourishing 
food. 

The  urinary  secretion  varies,  but  it  generally  presents 
some  abnormality.  Sometimes  it  is  scanty,  high- 
coloured,  and  deposits  urates  ;  in  other  cases  it  is  pale 
and  deposits  oxalate  of  lime  or  the  amorphous  phos- 
phates ;  in  others,  again,  it  is  abundant  and  contains 
traces  of  sugar. 

Symptoms  referable  to  the  organs  of  generation  are 
seldom  absent.  In  men,  these  take  the  form  of 
nocturnal  emissions  and  impotence,  while  women  are 
apt  to  suffer  from  various  disorders  of  menstruation. 

In  order  to  complete  this  sketch  of  the  symptoms  of 
neurasthenia  some  account  must  be  given  of  those 
evidences  of  psychical  disorder  which  are  rarely  absent. 
In  one  class  of  cases  these  symptoms  appear  to  pre- 
dominate, inasmuch  as  the  patients  constantly  dwell 
upon  them  in  conversation  and  show  by  their  actions 
and  manners  the  influences  by  which  they  are  swayed. 
Such  symptoms  as  apathy,  hopelessness,  morbid  excita- 


SYMPTOMS  OF  NEURASTHENIA.  39 

bility  and  irritability,  groundless  anxiety  and  fear, 
indifference  and  want  of  resolution  are,  if  not  charac- 
teristic of  neurasthenia,  at  least  seldom  dissociated  from 
it.  The  various  kinds  of  morbid  dread  are  among  the 
most  striking  of  the  mental  phenomena.  Some  patients 
fear  to  be  alone,  others  have  a  horror  of  societv  and  of 
certain  localities;  others  again  are  in  constant  fear  of 
being  attacked  by  disease,  while  in  another  class  there  is 
a  constant  but  undefined  dread  of  impending  danger  or 
misery.  Some  bf  these  patients  are  averse  to  remain  in 
rooms  with  windows  and  doors  closed  ;  others  are  in 
perpetual  fear  of  being  injured  by  lightning  or  some 
convulsion  of  nature.  Hallucinations  and  illusions  are 
rare  in  these  cases,  and  some  of  the  patients  are  fully 
aware  of  the  groundless  nature  of  their  fears.  Intense 
excitement  and  anxiety  about  the  merest  trifles  are  other 
common  symptoms  indicative  of  perverted  action  of  the 
sensorium. 

In  almost  every  form  of  nervous  disorder,  disturbed 
sleep,  often  amounting  to  utter  sleeplessness,  is  very 
generally  observed,  and  it  tends,  perhaps,  more  than  any- 
thing else  to  exaggerate  all  the  other  symptoms.  In 
some  cases  the  patients  remain  awake  for  hours  after 
going  to  bed  ;  in  others,  they  fall  asleep  easily,  but  wake 


40  SYMPTOMS  OF  NEURASTHENIA. 

in  an  hour  or  so  and  continue  in  that  condition  till  it  is 
time  to  get  up.  Even  the  sleep  that  is  obtained  is  apt 
to  be  troubled  by  dreams  and  nightmare,  and  the  patients 
rise  from  their  beds  more  languid  and  tired  than  when 
they  sought  them.  In  some  patients  the  sleep  is 
abnormally  profound,  but  the  patients  are  so  little 
refreshed  by  it  that  they  remain  drowsy  and  lethargic 
during  the  day,  unable  to  attend  to  business,  and  faUing 
fast  asleep  after  making  the  slightest  effort.  The  memory 
is  apt  to  be  affected  in  many  cases  of  neurasthenia,  and 
the  patients  are  much  worried  at  finding  that  after  read- 
ing a  short  paragraph  in  a  book  or  newspaper  they  fail 
to  remember  its  contents.  In  som.e  cases  arithmetical 
calculations,  previously  quite  easy,  appear  impossible; 
any  attempt  of  this  character  is  followed  by  confusion, 
headache,  swimming  before  the  eyes,  and  other  troubles. 

It  need  hardly  be  said  that  all  the  above-mentioned 
symptoms  of  neurasthenia  are  never  met  with  in  a 
single  patient ;  the  manner  in  which  they  are  grouped 
and  distributed  varies  to  an  almost  unlimited  extent. 

The  symptoms  of  neurasthenia  may  last  for  an 
indefinite  time,  and  in  slight  cases  are  apt  to  subside 
and  recur  at  irregular  intervals.  In  more  severe  cases 
the  condition,  in  the  absence  of  proper  care  and  treat- 


DIAGNOSIS  OF  NJEUR ASTHENIA.  41 

ment,  gradually  becomes  \vorse_,  and  is  a  source  of  much 
■anxiety  to  the  patient  and  his  friends.  Here,  again, 
improvements  and  relapses  are  wont  to  alternate,  and  it 
is  difficult  to  forecast  the  duration  of  the  symptoms. 
The  condition  is  not  serious  so  far  as  danger  to  life  is 
concerned,  but  it  may  be  the  starting-point  of  grave 
nervous  disease.  When  an  obvious  cause  is  discover- 
able and  capable  of  removal,  a  hopeful  prognosis  may  be 
given.  It  is,  of  course,  necessary  to  take  into  considera- 
tion the  state  of  the  patient,  the  surrounding  circum- 
stances, and  the  duration  of  the  symptoms. 

Diagnosis.  This  is  sometimes  easy,  especially  when 
a  causal  connection  can  be  established  between  the 
symptoms  and  their  antecedents,  but  in  other  cases  it 
can  be  made  only  per  viam  exclusionis,  and  by  carefully 
watching  the  patient  and  noticing  the  effect  of  treat- 
ment. In  some  severe  cerebral  diseases,  e.g.,  tumours, 
the  symptoms  closely  resemble  those  of  neurasthenia. 
The  recognition  of  the  temperament  of  the  patient  will 
sometimes  aid  the  dia2:nosis.  The  duration  of  the 
symptoms  and  the  occurrence  of  relapses  and  improve- 
ments are  other  points  of  importance.  In  some  respects 
the  symptoms  resemble  those  of  hysteria,  but  there  are 
decided  differences    between   the  two  conditions.     The 


42  TRJEATMBNT  OF  NEURASTHENIA. 

sudden  appearance  of  the  phenomena,  their  rapid  sub- 
sidence^ and  the  manner  in  which  they  are  excited  are 
sufficient  to  distinguish  hysteria  from  neurasthenia. 
The  former  is  liable  to  assume  the  more  serious  aspect, 
inasmuch  as  paralyses  and  spasmodic  attacks  are  prone 
to  occur  j  but  severe  cases  of  neurasthenia  would  appear 
to  be  connected  with  graver  states  of  disorder  of  the 
nervous  system. 

Treatment.  Provided  that  no  organic  disease  is  dis- 
coverable after  careful  examination  (and  I  am  treating 
only  of  such  cases),  the  physician  should  do  his  utmost 
to  comfort  and  reassure  his  patient  at  the  same  time 
that  he  impresses  upon  him  the  necessity  of  obeying 
all  injunctions.  The  patient^s  fears  must  be  allayed, 
though  it  will  be  often  difficult  to  do  this,  especially  in 
hypochondriacal  cases.  The  physician  must  frequently 
see  his  patient  and  assure  himself  that  his  prescriptions 
are  attended  to  in  all  respects.  In  cases  in  which 
sleeplessness  is  a  marked  symptom,  and  is  evidently 
causing  great  distress,  it  is  necessary  to  deal  with  it  at 
once  before  attending  to  the  general  condition.  Much 
caution  must,  however,  be  used  in  the  employment  of 
hypnotics.  We  may  choose  between  chloral  and  the 
bromides,  and  a  combination  of  these  remedies  is  oftea 


TEJEA  THE  NT  OF  3^Z  URA  S  THJENIA .  43 

better  than  either  taken  singly.  Twenty  grains  of 
bromide  of  ammonium  with  fifteen  of  chloral  may  be 
given  every  night  for  three  or  four  nights.  If  the  effect 
be  satisfactory  the  medicines  should  be  discontinued,  or 
given  for  a  few  nights  in  half  doses.  The  production 
of  sleep  greatly  assists  the  action,  of  other  remedies. 

Freedom  from  mental  exertion  is  the  next  point  of 
importance^  though  it  is  often  necessary  to  find  some 
employment  for  the  mind.  The  brain  will  not  suddenly 
take  rest ;  trains  of  action  set  going  in  the  cerebrum 
refuse  to  come  to  a  full  stop^  and  the  best  thing  to  be 
done  is  to  divert  the  cerebral  activity  into  other  channels. 
How  to  effect  this  object^  depends,  of  course,  upon  the 
individuality  of  the  patient ;  but  some  real  amusement 
(in  the  true  sense  of  the  word)  should  be  carefully 
sought  for.  The  patient's  tastes  must  be  consulted,  and 
they  will  often  guide  the  physician  in  selecting  the  best 
forms  of  recreation.  The  same  remark  holds  good  of 
bodily  exercise.  Patients  even  of  weak  muscular  power 
are  apt  to  think  that  violent  exercise  will  cure  their 
nervousness.  This  idea  is,  of  course,  a  mistaken  one, 
and  should  not  be  allowed  to  be  acted  upon.  The  exer- 
cise should  be  strictly  proportioned  to  the  strength  and 
should  never  be  such  as  to  cause  fatigue.     Short  walks,. 


44  TREATMENT  OF  NEURASTHENIA. 

carriage  exercise^  riding  on  horseback,  boating,  etc.,  will 
find  their  appropriate  uses.  A  change  to  fresh  air, 
either  in  the  country  or  by  the  seaside,  or  in  mountainous 
-districts,  will  always  be  beneficial,  and  it  is  hardly  neces- 
sary to  add  that  all  causes  of  debility  should  be  carefully 
avoided.  In  phlegmatic  subjects,  with  fair  muscular 
development,  exercise  is  often  an  important  part  of  the 
treatment.  Besides  the  forms  above  recommended, 
some  kinds  of  easy  gymnastics  may  be  had  recourse  to  ; 
Dr.  Zander's  instruments  are  very  suitable  for  such 
cases. 

The  diet  also  demands  very  careful  attention.  The 
majority  of  the  patients  are  thin  and  anaemic,  with  poor 
appetites  and  weak  power  of  digestion.  The  condition 
of  the  stomach  must  be  improved  by  tonics  of  various 
kinds,  of  which  nux  vomica  is  generally  the  most  useful. 
The  tincture  should  be  given  in  small  doses  (ntv-x) 
about  half-an-hour  before  each  meal.  The  food  should 
be  of  an  easily  digestible  nature,  and  it  is  well  to  provide 
these  patients  with  a  diet-sheet  telling  them  what  they 
may  eat  and  what  they  must  abstain  from.  Mutton  and 
beef,  white  fish,  game,  chicken  and  eggs,  butter,  milk, 
good  bread,  and  green  vegetables  well  cooked,  will  con- 
•Stitute    the    principal    articles    of  diet.      Late    dinners 


TREA  T3IE  NT  OF  NE  UFA  STRENIA .  45 

should  be  avoided ;  the  principal  meal  should  be  taken 
at  2  p.m.,  and  a  light  supper  at  seven  o'clock.  Where 
loss  of  flesh  has  been  a  marked  symptom,  increase  of 
weight  is  one  of  the  best  indications  of  recovery. 
Tobacco-smoking  should  be  forbidden,  especially  in 
cases  in  which  the  symptoms  are  attributable  to  excess 
in  this  respect.  Extreme  caution  is  required  in  recom- 
mending alcoholic  drinks  ;  if  allowed,  they  should 
never  be  taken  except  with  food.  A  glass  or  two  of 
sound  sherry,  claret,  or  Burgundy  will  be  serviceable  in 
most  cases,  and  particularly  when  the  digestion  is  feeble 
and  the  appetite  poor.  A  little  brandy  or  whisky,  well 
diluted,  may  also  be  given  at  bedtime;  it  often  aids  in 
procuring  sleep. 

With  regard  to  drugs,  tonics,  of  course,  are  generally 
indicated ;  nux  vomica  has  been  already  alluded  to  ; 
quinine  and  coca  wine  or  pastils  are  likely  to  be  useful, 
and  various  preparations  of  iron  are  indicated  in  anaemic 
cases.  Cod-liver  oil  is  one  of  the  best  roborants  that  we 
possess  j  if  tolerated  by  the  stomach  it  will  almost  cer- 
tainly do  good  in  these  cases.  The  hypophosphites  (in 
various  combinations)  are  medicines  of  great  efficacy  in 
some  cases  of  nerve-prostration.  When  oxaluria  is  pre- 
sent the  nitromuriatic  acid  is  the  best  remedy  ;  it  should 


46  TBEATIIENT  OF  NEURASTHENIA. 

be  combined  with  nux  vomica  and  the  tinctures  of  hen- 
bane and  hops.  Mild  laxatives  and  regulation  of  the  diet 
-should  suffice  for  the  relief  of  constipation  if  present. 
Strong  purgatives  are  quite  out  of  place,  and  the  patient 
should  be  warned  against  the  use  of  those  aperients  which 
are  so  freely  advertised.  The  skin  should  be  carefully  at- 
tended to  ;  few  of  these  patients  can  bear  a  cold  bath^  but 
a  tepid  bath,  or  sponging  with  tepid  water^  should  never 
be  neglected.  If  the  patient  can  be  sent  to  the  seaside, 
a  warm  salt-water  bath  taken  daily  will  constitute  an 
excellent  tonic. 

As  in  many  other  nervous  ailments,  electricity  has 
been  often  used  in  the  treatment  of  neurasthenia,  and  in 
not  a  few  cases  with  very  good  results.  For  this 
purpose  the  galvanic  current  of  moderate  strength  may 
be  applied  to  the  spine  for  about  ten  minutes  daily. 
General  faradization  is  another  method;  the  patient, 
stripped  of  his  clothes,  places  both  feet  on  a  large 
flat  electrode,  while  the  other  conductor,  covered  with  a 
sponge,  is  applied  to  various  parts  of  the  body.  It  has 
also  been  recommended  that  the  physician  should  take 
the  second  electrode  in  one  hand  and  apply  the  other  to 
the  patient's  body.  The  faradic  brush  may  likewise  be 
applied  along  the  spine  and  to  the  extremities ;  it  will 


TREATMENT  OF  NEURASTHENIA.  47 


be  found  especially  serviceable  when  there  are  symptoms 
•of  spinal  irritation.  The  electric  bath  presents  another 
method  of  using  electricity. 

In  a  somewhat  large  class  of  neurasthenic  subjects  a 
mode  of  treatment  introduced  and  perfected  by  Dr. 
Weir  Mitchell  is  followed  by  the  happiest  results.  The 
main  elements  of  this  method,  as  described  by  its 
author^  are  entire  rest  and  excessive  feeding,  rendered 
possible  by  passive  exercise  obtained  through  the  steady 
use  of  massage  and  electricity.  This  treatment  is 
especially  suitable  for  anaemic  women  with  little  or  no 
appetite,  always  tired,  spending  their  days  in  bed  or  on 
a  sofa,  and  with  no  power  of  volition  or  action.  Various 
hysterical  manifestations  and  more  or  less  spinal  tender- 
ness are  often  present  in  these  cases.  Such  a  condition 
sometimes  follows  a  season  of  trial  or  prolonged  anxiety, 
or  it  may  be  due  to  some  severe  illness,  from  which  the 
patient  has  never  entirely  recovered.  In  another  class 
of  cases  there  has  been  some  local  uterine  disorder,  the 
symptoms  of  which  remain,  though  the  affection  itself 
has  been  cured.  In  all  such  patients  it  frequently  hap- 
pens that  stimulants,  opiates,  and  the  bromides  have 
been  tried,  but  only  with  the  result  of  aggravating  all 
the  symptoms. 


48  TRBA  THE  NT  OF  NE  URA  STHENIA . . 

Dr.  Mitchell  describes  another  class  of  cases  for 
whom  the  treatment  is  equally  suitable.  In  these  the 
principal  symptoms  are  loss  of  flesh  and  colour,  various 
aches  and  pains,  but  no  organic  disease,  and  no  indica- 
tions of  hysteria.  All  that  clearly  appears  is  that  the 
patient  is  considerably  below  the  normal  standard  of 
health.  Such  cases,  as  well  as  the  more  severe  ones 
just  mentioned,  are  hard  to  cure.  Tonics  of  all  kinds 
are  of  little,  if  any,  value.  The  treatment  must  be 
directed  towards  increasing  the  weight  of  the  body  (and 
notably  the  quantity  of  fat),  and  the  number  of  red 
blood-corpuscles.  If  these  objects  can  be  effected  the 
disorders  of  the  stomach,  bowels,  and  uterus  will  rapidly 
subside.  Dr.  Mitchell  sums  up  his  directions  thus : — 
^^  Alter  the  moral  atmosphere,  add  to  the  weight,  and 
fill  the  vessels  with  red  blood."" 

The  principal  details  of  this  treatment  are  as  fol- 
lows : — 

1.  The  patient  must  be  isolated  from  her  friends^ 
and  placed  in  the  charge  of  a  trustworthy  nurse.  This 
seclusion  is  absolutely  necessary  for  emotional  women 
fond  of  dwelling  upon  their  ailments,  exaggerating 
everything  that  they  really  suffer  in  order  to  gain  sym- 
pathy and  indulgence,  and  to  whom  a  state  of  ill-health 


TREATMENT  OF  NEURASTSENIA.  49 

has  become  perfectly  natLiral.  Isolation  is  less  necessary 
for  feeble  anaemic  women  whose  loss  of  vitality  is  due 
to  obvious  causeSj  such  as  over-work  or  prolonged 
anxiety. 

2.  The  patient  must  be  kept  at  rest,  which  to 
be  effective  should  be  absolute_,  and  continued  for  six 
weeks  or  two  months.  Occupation  should  be  provided 
for  the  mind,  and  for  this  purpose  the  patient  should  be 
read  aloud  to  for  several  hours  daily^  but  all  sources  of 
excitement  should  be  carefully  guarded  against.  Dr. 
Mitchell  points  out  that  nervous  and  anaemic  women 
take  kindly  to  the  absolute  rest.  The  day  is  filled  up 
with  the  massage,  the  use  of  the  galvanic  battery,  the 
administration  of  food,  and  the  doctor's  visits,  and  by 
the  fifth  or  sixth  day  a  feeling  of  ease  is  generally 
experienced.  The  patient  must  not  leave  her  bed  for 
any  purpose  whatever;  all  excreta  should  be  passed 
while  she  is  lying  down.  There  are  many  moral 
benefits  attached  to  this  enforced  rest  and  isolation. 
The  patient  is  not  allowed  to  discuss  her  symptoms, 
save  with  her  medical  attendant,  and  she  cannot  fail  to 
profit  by  the  substitution  of  quiet  and  order  and  simple 
diet,  with  absence  of  drugs,  for  irregular  hours,  frequent 
use   of  remedies,  and  the  too  often  mischievous  sym- 

4 


50  TREATMENT  OF  FEUMASTHENIA. 

pathy  of  her  immediate  friends.  Such  absolute  rest 
would,  however,  be  attended  by  various  untoward  con- 
sequences and  difficulties,  and  steps  have  to  be  taken  to 
counteract  these.  The  muscles  require  to  be  exercised, 
for  if  not  the  circulation  will  become  feeble,  the  appetite 
will  fall  oiF,  and  the  digestion  will  suffer. 

3.  To  avert  the  consequences  just  mentioned  the 
muscles  should  be  thoroughly  shampooed  in  order  to 
produce  tissue  waste.  Before  commencing  this  process 
the  patient  should  be  placed  en  milk  diet  for  a  few 
days  j  the  rubber  should  then  be  instructed  to  shampoo 
the  muscles  of  the  limbs^  thorax,  and  abdomen  twice 
daily,  at  first  for  half-an-hour,  and  by  degrees  for  an 
hour  or  an  hour-and-a-half  each  time.  After  these 
rubbings  the  patient  at  first  feels  somewhat  exhausted, 
but  when  they  have  been  practised  for  a  few  days  a 
pleasant  feeling  of  lassitude  is  all  that  is  experienced. 
Either  galvanism  or  faradism  is  had  recourse  to  in  order 
to  improve  the  nutrition  of  the  muscles,  and  to  stimulate 
the  cutaneous  circulation.  Either  current  may  be  used 
for  about  twenty  minutes  twice  or  three  times  a  day. 
The  rubbings. and  the  galvanism  produce  a  considerable 
amount  of  waste  of  the  muscles  thus  exercised,  and  this 
has  to  be  compensated  by  excessive  feeding. 


TREATMENT  OF  NEURASTHENIA. 


4.  As  a  matter  of  course  in  prescribing  the  diet  the 
condition  and  previous  history  of  the  patient  have  to  be 
borne  in  mind.  Following  Dr.  Weir  Mitchell,  we  begin 
with  milk,  which  is  especially  suitable  wherever  anaemia 
and  obesity  are  combined.  As  much  as  two  quarts  may 
be  given  daily  to  begin  with,  and  this  diet  generally 
relieves  all  the  symptoms  of  indigestion.  In  from  four 
to  seven  days  some  light  solid  food  may  be  given  with 
breakfast,  and  then  a  mutton  chop  as  midday  dinner, 
and  bread  and  butter  thrice  a  day.  About  the  tenth 
day,  supposing  that  the  rubbing  and  galvanism  have 
been  properly  applied,  three  full  meals  should  be  taken 
daily  with  three  or  four  pints  of  milk.  One  or  two 
ounces  of  malt  extract  «should  be  o;iven  before  each 
meal.  At  the  close  of  the  first  week  it  is  well  to 
supplement  the  diet  still  further  by  giving  one  pound  of 
beef  daily  in  the  form  of  raw  soup.  Stimulants  are  not 
desirable,  and  should,  as  a  general  rule,  be  avoided.  If^ 
however,  they  have  hitherto  been  taken  in  strict  modera- 
tion a  small  quantity  may  be  allowed  without  dis- 
advantage. This  enormous  amount  of  food,  associated 
as  it  is  with  the  exercise  involved  in  the  rubbings, 
seldom  causes  any  gastric  or  intestinal  troubles.  The 
usual   results  are  increase   of  appetite,  assimilation  of 


52  TREATMEls^T  OF  NEURASTHENIA. 

increased  quantity  of  nourishment^  and  a  rapid  growth 
of  flesh.  If  symptoms  of  indigestion  should  occur, 
the  substitution  of  milk  diet  for  a  day  or  two  will 
generally  be  sufficient  to  relieve  them. 

When  the  treatment  has  been  continued  for  a  suffi- 
cient length  of  time  the  patient  should  not  be  allowed 
to  get  up  and  stand  on  her  feet  too  suddenly.  She 
should  first  sit  up  in  bed  for  a  few  minutes  at  a  time, 
then  take  food  in  a  sitting  posture^  and  then,  after  a 
day  or  two,  be  allowed  to  sit  in  a  chair.  If  these  pre- 
cautions be  neglected  and  the  patient  attempt  to  walk 
about  or  even  to  stand  without  previous  preparation,  she 
is  almost  certain  to  be  troubled  by  attacks  of  giddiness 
and  palpitation  of  the  heart..  At  the  end  of  ten  or 
twelve  weeks  she  should  still  spend  three  or  four  hours 
in  bed  daily,  and  for  some  time  afterwards  should  make 
a  rule  of  lying  down  and  resting  after  exercise,  which 
should  be  taken  with  the  utmost  care. 

It  is  seldom  necessary  to  administer -any  medicines; 
but  in  highly  anaemic  cases  the  solution  of  dialysed  iron 
may  be  given  with  advantage.  Should  the  bowels  be- 
come constipated,  recourse  should  be  had  to  mild  laxa- 
tives. When  the  patient  sits  up.  Dr.  Mitchell  recom- 
mends that  she  should  take  one-thirtieth  of  a  grain  of 


TSIJATMEJVT  OF  NEURASTEENIA.  53 

Strychnine  thrice  daily.  As  a  matter  of  course,  the  room 
in  which  the  treatment  is  carried  out  should  be  large 
and  well  ventilated. 

In  properly  selected  cases  the  course  of  treatment  as 
above  described  yields  the  happiest  results.  The  symp- 
toms rapidly  disappear,  flesh  and  strength  are  gained, 
and  within  a  few  weeks  or  months  the  patient  is  restored 
to  complete  health.  Several  of  such  cases  have  lately 
been  under  my  care.  As  examples,  I  may  cite  three 
cases  of  hysteria  with  malnutrition  in  women,  two  over 
thirty  years  of  age,  and  bedridden  for  many  months 
previous  to  my  being  called  in.  Case  A,  age  32,  un- 
married, bedridden  for  fifteen  months,  and  weighing 
seven  stone  four  pounds.  After  seven  weeks'  treat- 
ment she  had  increased  22  pounds  in  weight,  and  was 
thenceforward  able  to  walk  and  resume  her  ordinary 
habits  of  life.  Case  B,  age  34,  married  J 5  years  ago^ 
and  had  one  child,  age  14.  The  death  of  the  latter, 
after  a  short  acute  illness,  was  soon  followed  by  the 
development  of  hysterical  and  neurasthenic  symptoms 
in  the  mother.  She  became  emaciated  and  bedridden, 
her  weight  falling  from  11  stone  12  pounds  to  eight 
stone  two  pounds.  She  practically  recovered  her 
health  after  eight  weeks'  treatment,  and   was   able  to 


54  TRJEATMUNT  OF  NHUEASTEENIA. 

walk  and  resume  her  ordinary  habits  of  life,  though  sub- 
ject to  occasional  fits  of  despondency.  She  gained  21 
pounds  in  weight  during  the  treatment.  Case  C  was 
that  of  a  young  lady,  age  19,  who  had  been  overworked 
at  school.  When  I  first  saw  her  she  had  been  bed- 
ridden for  three  months^  and  had  become  reduced  from 
nine  stone  ten  pounds  to  seven  stone  nine  pounds. 
She  was  full  of  fancies,  and  at  times  her  mind  wan- 
dered. Her  weight  rose  to  ten  stone,  and  she  made  a 
perfect  recovery  after  six  weeks^  treatment. 

One  or  two  points  have  to  be  carefully  borne  in  mind 
in  connection  with  the  Weir  Mitchell  treatment  of 
neurasthenia.  The  attention  of  the  profession  has 
lately  been  called  to  them  by  Dr.  Playfair.  In  the  first 
place  the  method  is  unsuitable  for  cases  in  which  organic 
lesions  exist :  its  employment  for  such  would  be  harm- 
ful^ and  would  raise  hopes  which  would  assuredly  be 
disappointed.  An  accurate  diagnosis  is  therefore  an 
essential  preliminary,  and  no  pains  should  be  spared  to 
determine  the  nature  of  the  case.  It  is,  however,  quite 
true,  as  pointed  out  by  Dr.  Playfair,  that  obscure  cases 
from  time  to  time  occur,  the  real  nature  of  which  can 
be  determined  only'  by  the  effects  of  treatment.  In 
another  class  of  cases,  viz.,  in  those  in  which  there  are 


TIiJEAT3IJSNT  OF  NEURASTHENIA.  55 

marked  evidences  of  mental  disorder,  the  method  is  in- 
appHcable  as  a  general  rule.  In  hysterical  cases  there 
may  be  much  difficulty  in  deciding  as  to  the  nature  of 
symptoms  of  mental  perversion,  and  a  cautious  trial  of 
the  method  may  sometimes  be  advisable.  The  last 
point  to  be  attended  to  is  that  the  method,  to  be  effec- 
tive, must  be  carried  out  in  its  entirety.  If,  for  instance, 
the  patient  be  allowed  to  get  up  from  time  to  time,  to 
receive  friends,  to  read,  do  needlework,  or  otherwise 
employ  herself,  a  satisfactory  result  cannot  be  antici- 
pated. 


CHAPTER  II. 

NEURASTHENIA  SPINALIS— SPINAL  IRRITATION. 

Neurasthenia  Spinalis,  a  Functional  Disorder — Its  Presumed 
Nature  —  Spinal  Irritation  —  Causes  of  Spinal  Neuras- 
thenia— Symptoms — Causes  of  Spinal  Irritation — Symptoms 
— Principal  Differences  between  Spinal  Neurasthenia  and 
Irritation — Diagnosis  and  Course  of  the  two  Conditions 
—  Their  Treatment  —  Dr.  Brown-Sequard's  Method  of 
Treating  Spinal  Irritation. 

It  was  stated  in  the  preceding  chapter  that  symptoms 
of  cerebral  neurasthenia  are  often  associated  with 
various  indications  of  spinal  disorder^  which  were 
briefly  described.  In  a  somewhat  numerous  class  of 
caseSj  however,  the  cerebral  symptoms  are  either  almost 
or  entirely  wanting,  while  those  referable  to  the  spinal 
cord  are  especially  prominent,  and  constitute  the  whole 
of  the  complaint.  The  symptoms  referred  to  may 
legitimately  be  attributed  to  functional  disorder,  inas- 
much as  the  objective  indications  of  organic  lesions  in 
the  cord  are  not  discoverable;  and  the  development, 
course,  and  frequent  curability  of  the  symptoms  further 
tend  to  support  the  belief  that  no  decided  anatomical 
changes  exist  in  any  part  of  the  nervous  system. 


SPINAL  NEURASTHENIA  AND  IRRITATION.      57 

As  to  the  condition  of  the  cord  in  these  cases,  we  can 
•only  hazard  a  guess  that  there  is  either  some  derange- 
ment in  the  nervous  mechanism,  some  change  in  its 
molecular  state  and  action,  or  some  disorder  of  the 
•circulation  due  to  abnormal  vaso-motor  action,  and 
interfering  with  nutrition.  A  persistent  condition  of 
anaemia  is  scarcely  probable.  Some  authorities  have 
supposed  that  the  symptoms  of  spinal  neurasthenia 
might  possibly  be  due  to  functional  disorder  of  the 
-cerebellum.  Whatever  may  be  the  actual  condition  of 
the  implicated  parts,,  the  symptoms  require  careful 
study,  inasmuch  as  they  are  liable  to  be  attributed  to 
the  presence  of  grave  lesions. 

The  symptoms  in  these  cases  of  functional  disorder 
of  the  spine  may  be  classified  under  two  heads:  (i) 
Those  in  which  debility  is  the  prominent  feature,  and 
(2)  those  in  which  the  sensory  nerves  of  the  spine  are 
in  a  state  of  morbid  excitability  indicated  by  severe  pain 
and  tenderness.  To  the  former  group  the  term  sp'mal 
neurasthenia  may  be  conveniently  applied,  while  the 
latter  constitutes  the  disorder  known  as  spinal  irrita- 
tion. It  is  impossible,  however,  to  draw  a  very  strict 
line  of  demarcation  between  the  two  classes,  as  cases 
often  occur  in  which  weakness  and  pain- are  combined 


s8  SPINAL  njeurasthi:nia. 

in  varying  proportions.  In  the  description  which 
follows  an  attempt  will  be  made  to  point  out  the 
similarities  and  the  differences  that  exist  between  the 
two  conditions;  they  will  first  be  described  separately 
and  then  compared.    . 

SPINAXi  NBURASTHIESNZA  is  more  common 
in  males  than  in  females^  and  the  patients  are  generally- 
young  adults  or  in  early  middle-age.  Hereditary  predis- 
position to  nervous  disorders  is  sometimes  traceable* 
The  exciting  causes  are  over-fatigue  of  all  kinds,  sexual 
excesses^  undue  indulgence  in  alcohol  and  tobacco^  late 
hours_,  and  insufficient  rest.  Sexual  excesses  are  the 
most  potent  as  well  as  the  most  common  of  these 
causeSj  and  their  effect  is,  of  course,  heightened  by  the 
simultaneous  operation  of  ajiy  of  the  remainder.  In 
some  cases  the  onset  of  the  symptoms  is  traceable  to 
previous  severe  illness,  and  it  not  unfrequently  happens 
that  slight  injuries  to  the  spine  are  followed  by  symp- 
toms closely  resembling  those  about  to  be  described. 

The   symptoms   of  spinal   neurasthenia  are   for    the 

most  part  gradual  in   their  mode  of  invasion,  and,  for 

some   time    after   their   commencement,    indefinite    in 

-character.    The  first  is  usually  a  feeling  of  undue  weari-^ 

ness  after  moderate  or  even  slight  exertion,  such  as  a 


SPINAL  NEURASTSBNIA. 


59 


short  walk.  The  patient  finds  that  his  legs  especially- 
soon  get  tired_,  and  by  degrees  he  becomes  conscious  of 
the  fact  that  exercise  is  no  longer  a  source  of  enjoyment. 
If,  as  is  sometimes  the  case,  he  tries  to  get  rid  of  this 
feeling  by  ^'  walking  it  off/'  he  is  soon  made  aware  of 
his  mistake.  A  disagreeable  sensation  of  pain  and 
stiffness  in  the  muscles  and  joints  is  added  to  the 
debility,  and  these  symptoms  are  out  of  all  proportion 
to  the  exercise  taken.  The  pain  is  apt  to  become 
localized  in  the  back  and  loins^  it  is  of  a  dull,  heavy 
character^,  and  is  sometimes  associated  with  a  sensation 
of  heat  in  those  parts.  There  is  seldom  any  decided 
tenderness  along  the  spine.  The  extremities,  and  es- 
pecially the  feet,  are  generally  cold  and  numb,  and  even 
when  the  patient  is  at  rest  pains  like  those  of  neuralgia 
are  often  felt  in  those  parts.  Loss  of  sleep  is  another 
symptom  common  in  these  patients,  and  when  present 
it  greatly  aggravates  the  feelings  of  debility,  and  the 
patient's  appearance  rapidly  becomes  altered  for  the 
worse.  When,  on  the  other  hand,  a  fair  amount  of 
sleep  is  obtained,  no  such  alteration  may  be  observed. 
Gastric  and  intestinal  disorders  are  often  superadded, 
though  they  seldom  become  very  prominent.  The 
appetite  may  remain  good,    and    indeed   may    become 


6o  SPINAL  IRRITATION. 

almost  voracious,  but  the  digestion  goes  on  slowly  and 
is  often  attended  with  more  or  less  pain.  Constipa- 
tion is  generally  present.  Palpitation  of  the  heart, 
giddiness,  and  a  feeling  of  weight  in  the  head  are  less 
commonly  noticed.  After  the  symptoms  have  existed 
for  some  time  the  patient  is  liable  to  fall  into  a 
desponding,  hypochondriacal  condition.  In  the  male 
subject,  involuntary  seminal  emissions  and  loss  of 
sexual  power  are  often  complained  of. 

SPINAIi  IRRITATION  is  far  more  common  in 
females  than  in  males,  and  the  majority  of  the  patients 
are  between  fifteen  and  thirty  years  of  age.  Hereditary 
tendency  to  neurotic  disorder  can  often  be  ascertained. 
The  exciting  causes  are  anaemia,  however  produced; 
Jactation  unduly  prolonged ;  insufficient  and  improper 
food  ;  over-fatigue  (especially  in  persons  unused  to 
much  exertion)  ;  insufficient  rest;  excessive  sexual 
intercourse;  slight  injuries  to  the  spine;  carrying 
heavy  weights,  etc.  Marked  symptoms  of  spinal 
irritation  are  sometimes  noticed  in  women  who  for 
weeks  or  months  have  been  engaged  in  nursing,  and 
have  paid  little  or  no  attention  to  their  own  comfort 
and  requirements.  Besides  the  above-mentioned  causes, 
mor-bid  states  of  the  mucous  membranes  may,  as 
pointed  out  by  Dr.  Quain,  give  rise  to  spinal  pain  and 


SFIXAL  IREITATIOK.  6i 

tenderness.  Thus  pain  in  the  cervical  spine  sometimes 
attends  congestion  of  the  pharynx  ;  pain  and  tender- 
ness in  the  dorsal  region  are  common  in  cases  of 
gastric  disorder,  while  the  lumbar  and  sacral  regions 
are  apt  to  be  affected  in  diseased  states  of  the  intestinal 
mucous  membrane  and  of  the  urinary  and  genital 
organs.  Hysterical  patients  often  complain  of  tender- 
ness and  pain  along  the  spine,  and  are  especially  prone 
to  aggravate  any  abnormal  sensation  of  this  kind,  how- 
ever slight,  by  keeping  the  attention  fixed  upon  it,  and 
investing  it  with  the  gravest  importance.  It  is  well 
known  that  subjective  sensations  may  be  actually  called 
into  existence  by  fixing  the  attention  on  parts  of  the 
body,  and  bv  the  belief  in  the  existence  of  objective 
causes  for  such  sensations. 

The  symptoms  of  spinal  irritation  are  of  a  multiform 
character.  It  would  appear,  indeed,  as  if  almost  any 
derangement  of  function  in  parts  of  the  body  supplied 
w'ith  nerves  from  the  spinal  cord  might  originate  from 
spinal  irritation.  The  tenderness  on  pressure  is,  how- 
ever, the  only  essential  symptom;  those  w^hich  are 
superadded  vary  in  character  and  severity  in  almost 
every  case.  The  tenderness  is  elicited  by  making 
careful  pressure  over  the  spinous   processes ;  its  most 


62  SPINAL  IRRITATION. 

common  seat  is  the  middle  and  lower  part  of  the  dorsal 
region,  but  it  may  be  discovered  in  almost  any  part  of 
the  spine.  It  may  be  confined  to  one  or  two  or  several 
vertebrae,  or  diffused  over  the  entire  column.  The 
tenderness  is  sometimes  slight,  but  more  often  ex- 
quisitely keen_,  so  that  the  least  touch  causes  un- 
easiness, and  firm  pressure  sets  up  excruciating  pain. 
In  some  patients,  nausea  and  faintness  accompany  the 
pain  thus  caused.  A  far  less  common  symptom  is 
spontaneous  pain  in  the  spine;  when  present  it  may 
correspond  with  the  tender  spot,  or  may  be  felt  else- 
where. The  skin  for  some  distance  around  the  tender 
part  is  often  morbidly  sensitive;  neuralgic  pains  are 
common  in  various  parts  of  the  body  and  in  the 
abdomen.  Various  other  abnormal  sensations,  such  as 
tingling,  itching,  feelings  of  cold,  etc.,  are  sometimes 
complained  of;  loss  of  sensation  is  rarely  noticed. 

Indications  of  motor  disorder  are  generall}  present 
though  they  are  seldom  very  marked.  They  appear  in 
the  form  of  lassitude  after  exertion  and  weakness  of  the 
muscles  of  the  limbs,  sometimes  amounting  to  paresis. 
In  rare  cases  there  are  fibrillary  twitchings,  and  even 
cloaic  spasms  of  various  muscles,  producing  movements 
like  those  of  chorea.     A  state   of  fixed  contraction  of 


SPINAL  IRRITATION.  63 

the  muscles  of  the  fore-arm^  remaining  even  during 
sleep^  has  been  noticed  in  some  cases.  Coldness  of 
the  hands  and  feet,  and  flushing  of  the  face,  alternating 
with  paleness,  are  indications  of  vaso-motor  disorder, 
and  are  usually  prominent  symptoms.  Other  signs  of 
functional  disorders  often  accompany  spinal  irritation. 
The  most  noticeable  of  these  are  difficult  deglutition, 
morbid  appetite,  excessive  thirst,  copious  eructations, 
vomiting,  palpitation  of  the  heart,  dyspnoea,  a  spas- 
modic cough,  spasm  or  irritability  of  the  bladder,  with 
frequent  and  copious  discharge  of  pale  urine,  spasm  of 
the  sphincter  ani,  uterine  and  ovarian  pains,  and 
menstrual  irregularities.  One  or  other  of  these  symp- 
toms may  become  so  severe  as  to  demand  special  atten- 
tion ;  the  varieties  which  occur  in  a  given  case  depend 
upon  the  localization  of  the  disorder  in  the  spine. 

Indefinite  symptoms  of  psychical  disorder  are  met 
with  in  some  cases.  Irritability  and  restlessness,  dis- 
turbed sleep,  and  decided  insomnia  are  the  most 
common  features  of  this  character. 

The  principal  differences  between  spinal  neurasthenia 
and  spinal  irritation  would  appear  to  be  as  follows  : 
The  former  is  most  common  in  males;  the  predominant 
symptoms  are  those  of  debility,  no  marked  tenderness 


64       SPINAL  NEURASTHIINIA  AND  IBRITATION. 

in  the  spine^  no  special  abnormal  sensations  except, 
neuralgic  pains ;  in  the  male  subject,  disorder  of  the 
generative  organs ;  indigestion,  and  constipation  often 
present.  Spinal  irritation  is  most  common  in  females 
under  thirty  years  of  age,  tenderness  in  some  portion 
of  the  spinal  column  is  the  principal  symptom ; 
neuralgic  pains  and  abnormal  sensations  are  frequent ; 
general  weakness,  symptoms  of  disordered  action  of  the 
thoracic  and  abdominal  organs  are  more  or  less 
commonly  present. 

The  diagnosis  of  spinal  neurasthenia  is  to  be  inade 
chiefly  per  v'lam  exclusionis.  There  are  no  evidences 
of  anv  organic  lesion  of  the  spine,  and  the  condition  of 
the  limbs  is  one  of  weakness  only,  not  of  paralysis. 
The  electrical  reactions  of  the  nerves  and  muscles  are 
normal,  and  there  is  no  tenderness  on  pressure  over  any 
of  the  nerve-trunks.  Exaggerated  tendon-reflexes  are 
noticed  in  some  cases,  but  this  symptom  is  not  per- 
sistent. 

The  diagnosis  of  spinal  irritation  is  less  easily  madcy 
inasmuch  as  the  account  given  by  the  patient  is  apt  to 
be  misleading.  This  complaint  is  frequently  met  with 
in  hysterical  subjects,  and  in  such  cases  it  is  by  no 
means    easy    to    discover  the  amount  of  pain  that  is 


TBEATMENT  OF  SPINAL  NEURASTHENIA.        65 

really  felt.  A  little  observation  will,  however,  show 
that  evidences  of  organic  disease  are  entirely  absent. 
Pain  and  tenderness  in  some  portion  of  the  spine  are 
common  symptoms  of  meningeal  inflammation,  but  in 
this  latter  affection  there  is  always  more  or  less  fever 
and  such  other  indications  of  serious  mischief,  as  reten- 
tion of  urine  and  faeces  and  paresis  or  decided  paralysis 
of  the  limbs.  In  reference  to  diagnosis,  it  must  be 
admitted  that  cases  presenting  the  symptoms  of  spinal 
irritation  are  not  unfrequently  placed  in  the  category  of 
hysteria.  In  like  manner  spinal  neurasthenia,  with 
symptoms  of  dyspepsia,  is  often  regarded  as  a  form  of 
indigestion;  and  when  the  patient  is  decidedly  hypochon- 
driacal, the  nomenclature  of  the  affection  depends 
upon  the  view  taken  by  the  physician. 

The  course  of  the  two  affections  under  consideration 
is  almost  invariably  chronic;  improvements  alternate 
with  relapses,  and  even  under  the  most  favourable  cir- 
cumstances and  judicious  treatment  the  symptoms 
may  last  for  months  or  even  years.  The  prognosis, 
however,  is  almost  always  favourable,  provided  that  the 
necessary  remedies  be  adopted. 

The  treatment  of  spinal  neurasthenia  consists  first  in 
the  careful   avoidance  of  all  causes  likely  to  produce 

5 


66         TEBATMENT  OF  SPINAL  NBUMASTHENIA. 

debility,  and  secondly  in  the  adoption  of  measures  calcu- 
lated to  improve  the  general  health.     Rest  of  body  and 
mind  is  absolutely  essential,  and  excesses  of  all  kinds 
must  be  scrupulously   interdicted.     As  in  many  other 
affections  of  the  nervous  system,  a  proper    amount  of 
sleep  is  of  the  highest  importance ;  in  the  absence  of 
this  desideratum,  little  or  no  progress   will  be  made. 
Sleeplessness  and  the  various   methods  of  dealing  with 
it  will  be  discussed  in  a  succeeding  chapter ;  it  is  suffi- 
cient here  to  say  that  in. these  cases  of  neurasthenia 
narcotics  must  be  used  with  the  greatest  caution.  They 
are  often  indispensable,  but  patients  are  only  too  apt  to 
continue  their  use  until  a  so-called  "  habit  '^  results,  and 
the  end  is  worse  than  the  beginning.  For  procuring  sleep 
the  physician  has  to  choose  between  morphine,  chloral_, 
and    the  bromides,   and    a    combination  of    the  three 
drugs  in   small  doses  sometimes  acts  better  than  any 
one  of  them  given  singly.     On  the  whole  the  bromides 
are  the  safest,  but  their  use  most  not  be  prolonged.     If 
they    fail,    a    little    chloral   should  be  added,  and    the 
morphine  held  in  reserve,  to  be  tried  if  necessary.     The 
diet  should  be  generous  and  easily  digestible ;  stimu- 
lants in  moderation  should  be  allowed  according  to  cir- 
cumstances.    Burton  ale  is  one  of  the  best,  and  among 


TSjEATMENT  of  spinal  inniTATION.  67 

wines  sound  Burgundy  is  perhaps  the  most  suitable. 
Fresh  air^  either  in  a  good  country  district  or  at  the  sea- 
side, will  greatly  assist  all  other  remedies  ;  and  when 
the  patient  has  gained  a  little  strength  mountain-air  is 
likely  to  be  of  service.  The  skin  should  be  properly 
attended  to;  tepid  baths  and  even  cold  sponge-baths 
are  to  be  advised  according  to  circumstances.  With 
regard  to  drugs^  tonics  of  various  kinds  are  always 
indicated.  Iron,  quinine_,  and  strychnine  are  the  most 
potent  remedies  of  this  character,  and  may  be  given 
separately  or  in  combination. 

The  treatment  of  spinal  irritation  resembles  in  general 
details  that  of  neurasthenia,  but  certain  local  measures 
require  to  be  superadded.  It  is  necessary  to  relieve  the 
pain  and  tenderness,  and  for  this  purpose  the  subcu- 
taneous injection  of  morphine  or  atropine  is  most 
efficacious.  It  should,  however,  be  reserved  for  severe 
cases;  the  anodyne  liniments  (opium,  belladonna, 
aconite,  and  chloroform),  variously  combined,  will 
suffice  to  relieve  lesser  degrees  of  pain,  and  should  be 
first  tried  in  all  cases.  Should  the  local  use  of  the 
anodynes  prove  unsuccessful,  counter-irritants  may  next 
be  thought  of.  When  the  pain  is  confined  to  two  or 
three  vertebrae,   a  small  blister  (about  the  size  of  half- 


68  TREATMENT  OF  SPINAL  IRRITATION. 

a-crown)  may  be  applied  over  the  transverse  processes 
on  each  side.  It  is  sometimes  necessary  to  apply 
several  blisters  in  succession  over  new  portions  of  skin ; 
but  it  is  undesirable  to  produce  more  than  slight  vesica- 
tion. The  application  of  croton-oil  or  tartar  emetic 
ointment  is  not  to  be  recommended.  Sometimes  a 
rubefacient  liniment  will  answer  as  well  as  blistering, 
and  Liniment.  Sinapis  Comp.  may  be  used  for  the 
former  purpose.  Ice  applied  in  one  of  Dr.  Chapman's 
bags  for  a  few  minutes  daily  will  sometimes  prove  suc- 
cessful after  other  means  have  failed.  When  the 
tenderness  and  pain  are  not  localized^  but  more  or  less 
diffused  over  the  whole  spine,  the  application  of  the 
actual  cautery  in  the  manner  recommended  by  Dr. 
Brown-Sequard  is  often  followed  by  the  best  results.  It 
would,  however,  be  difficult  to  use  the  cautery  to  a  highly 
nervous  patient,  though  the  amount  of  pain  it  causes  is 
really  quite  insignificant.  Unless  marked  hyperaesthesia 
exists,  a  little  burning  or  tingling  sensation,  lasting 
for  a  few  minutes,  is  all  that  is  generally  complained 
of.  The  Paquelin  cautery  is  a  very  convenient  instrument 
for  the  purpose,  and  Dr.  Brown- Sequard's  rules  for  its 
application  should  be  closely  observed.  They  are  as 
follows  :  A  small  instrument  should  be    selected  and 


TRIEATMENT  OF  SPINAL  IRRITATION.  69 

raised  to  a  white  heat ;  it  should  be  drawn  firmly,  but 
very  quickly,  over  the  skin  for  two  or  three  inches  on 
each  side  of  the  spine,  making  several  linear  cauteriza- 
tions parallel  to  each  other.  It  is  well  to  begin  in  the 
cervical  region,  and  to  repeat  the  operation  daily  or  every 
other  day  until  the  whole  length  of  the  spine  has  thus  been 
treated.  Some  eight  or  ten  applications  will  thus  be  re- 
quired. If  the  cautery  be  properly  used,  the  result  will  be 
that  the  superficial  layers  of'  the  epidermis  become  dry 
and  yellowish;  vesication  should  never  be  produced.  This 
plan  of  treatment  is  adapted  for  severe  cases,  and  if 
carried  out  as  above  directed  will  yield  excellent  results. 
In  cases  in  which  the  spinal  symptoms  form  part  of 
the  phenomena  of  hysteria  and  there  are  marked  evi- 
dences of  profound  nervous  exhaustion,  the  plan  of 
treatment  known  as  Weir  Mitchell's,  and  described  in  a 
previous  chapter  (see  p.  47),  is  well  worthy  of  adoption. 
Every  care  should  be  taken  in  the  diagnosis,  for,  as 
already  stated,  the  treatment  referred  to  is  not  suitable 
for  any  form  of  organic  disease. 


CHAPTER  III. 

SLEEPLESSNESS. 


Sleeplessness  in  Nervous  Disorders — Conditions  requisite  for 
Normal  Sleep — Causes  of  Sleeplessness — Vascular  Excite- 
ment— Phesence  of  Imperfectly  Oxidized  Materials  in  the 
Blood — Indigestion — Anxiety  and  Excitement — Cold  and 
Heat — Sleeplessness  in  Elderly  Persons — External  Causes 
OF  Sleeplessness — Want  of  Exercise — Treatment  of  Sleep- 
lessness— Importance  of  Ascertaining  Cause — Question  of 
Diet — Treatment  of  Gouty  Subjects — Hypnotics  for  Cases 
Due  to  Anxiety — ^Various  Plans  for  Dealing  with  Different 
Cases. 

Sleeplessness  in  varying  degrees  is  a  common  symptom 
of  nervous  disorders,  and  when  present  decidedly  aggra- 
vates the  patient's  condition.  On  the  other  hand,  rest 
of  body  and  mind  is  a  most  important  part  of  the  treat- 
ment of  all  affections  of  the  nervous  system,  and  par- 
ticularly of  those  which  exhibit  the  symptoms  of  neu- 
rasthenia. This  latter  affection  has  been  described  in 
the  preceding  chapters,  and  the  present  would  appear  to 
be  a  fitting  place  for  discussing  the  causes  and  treat- 
ment of  sleeplessness.  There  is  another  reason  why 
this  symptom  deserves  to  be  separately  described.  At  the 


SLEEPLESSNESS.  71 

present  day  physicians  have  to  deal  with  not  a  few 
cases  in  which  wakefuhiess  or  sleeplessness  seems  to 
constitute  the  whole  of  the  disorder;  they  are^  at 
all  events,  the  symptoms  for  which  advice  is  sought. 

The  amount  of  sleep  necessary  for  individuals  in  health 
varies  within  certain  limits,  but  for  adults  7  to  8 
hours  may  be  said  to  be  the  average.  Some  persons 
require  more,  while  others  can  do  withless^  though  it  is 
certain  that  injury  often  follows  protracted  mental 
activity  carried  on  with  perhaps  only  4  or  5  hours 
rest  daily.  A  periodical  suspension  of  the  activity  of 
the  brain  and  its  ganglia  is  a  necessary  condition  for 
their  repair.  During  sleep  a  diminished  supply  of  blood 
is  received  by  the  brain_,  and  the  movement  of  the  blood 
in  the  vessels  is  less  rapid  than  during  the  waking 
hours.  Dr.  Hughlings  Jackson  has  observed  that  during 
sleep  the  optic  disc  is  whiter  in  colour,  the  arteries 
smaller,  the  veins  somewhat  larger,  and  the  neighbour- 
ing portion  of  the  retina  more  anaemic.  Unless  this 
comparatively  anaemic  condition  of  the  brain  exists, 
normal  sleep  is  impossible. 

The  causes  of  sleeplessness  are  many  and  various^ 
but  vascular  excitement  is  the  result  which  most  of  them 
produce.     Thus,  in   many  cases  the  immoderate  use  of 


72  CA  USJES  OF  SLBEPLFSSNUSS. 

alcohol,  coffee^  tea^  or  tobacco  is  a  direct  preventive  of 
sleep.  Another,  and  a  common  cause  of  sleeplessness, 
is  the  accumulation  in  the  blood  of  imperfectly  oxidized 
materials.  This  condition  is  frequent  in  gouty  subjects, 
and  especially  in  those  whose  kidneys  are  affected.  The 
cardiac  hypertrophy,  so  common  in  these  cases,  is  asso- 
ciated >A'ith  excessive  tension  in  the  cerebral  arteries. 
The  effect  of  an  attack  of  indigestion  in  preventing  sleep 
is  well  known ;  it  is  produced  in  a  two-fold  manner,  a 
distended  stomach  interferes  with  the  heart's  action, 
and  imperfectly  assimilated  products  present  in  the  blood 
cause  cerebral  hyperaemia  and  probably  irritate  the 
cerebral  cells. 

Sleep  is  often  prevented  by  anxiety  or  excitement. 
At  the  present  day,  when  so  many,  either  from  choice 
or  necessity,  spend  their  time  in  passing  from  one  form 
of  excitement  to  another,  when  such  an  enormous 
amount  of  work  or  play  has  to  be  got  through  in  a 
limited  number  of  hours,  it  is  not  to  be  wondered  at 
that  sleeplessness  is  so  common  a  trouble,  or  that 
specifics  for  its  relief  should  be  so  eagerly  sought  after 
and  so  recklessly  employed.  In  some  cases  compara- 
tively slight  causes  are  sufficient  to  render  the  individual 
sleepless,  and  especially  if  they  operate  late  in  the  day. 


CAUSES  OF  SLEEPLESSNESS.  7^ 

I  have  now  a  gentleman,  aged  47^  under  my  care^  in 
whom  sleeplessness  is  invariably  caused  by  the  receipt 
of  an  important  letter  or  telegram  during  the  evening. 
If  such  news  be  received  earlier  in  the  dav  there  are  no 
ill  effects. 

Sleeplessness  is  sometimes  induced  by  the  discomfort 
arising  from  cold.  In  winter  time  persons  leaving  a 
warm  room  where^  perhaps  for  an  hour  or  two  pre- 
viously, they  had  scarcely  been  able  to  keep  their  eyes 
open,  sometimes  find  themselves  quite  unable  to  sleep 
on  going  to  bed  in  a  room  without  a  fire.  The  warmth 
of  the  sitting-room  relaxed  the  skin,  caused  its  blood- 
vessels to  become  filled,  and  produced  an  opposite  state 
of  things  in  the  brain.  The  cold  of  the  bed-room 
reversed  these  conditions,  and  if  the  difference  between 
the  two  temperatures  be  very  great,  perhaps  20  degrees 
or  more,  the  waking  state  may  be  prolonged  for 
hours. 

Great  heat,  again,  may  prevent  sleep  ;  in  this  case 
the  supply  of  blood  to  the  brain  is  increased,  owing  to 
the  more  frequent  action  of  the  heart. 

Sleeplessness  is  sometimes  a  great  trouble  to  elderly 
persons,  in  whom  the  smaller  cerebral  arteries  are  in  a 
state  of  degeneration.     The  elasticity  of  the  vessels  is 


74  C^  USES  OF  SLEEPLESSNESS. 

much  diminished,  and  they  remain  in  a  more  or  less 
dilated  state.  It  is  almost  unnecessary  to  add  that 
pain  of  any  kind  may  keep  a  person  awake  the  whole 
night  through.  Persons  are  often  rendered  wakeful  or 
sleepless  by  external  causes,  such  as  too  much  light  or 
noise;  both  act  as  direct  stimulants,  whereas  silence 
and  darkness  have  a  calming  and  soothing  influence, 
and  predispose  to  sleep.  In  some  cases,  however, 
monotonous  noises  tend  decidedly  to  produce  sleep ;  the 
ticking  of  a  clock,  and  the  sound  of  distant  waters  are 
usually  favourable  in  this  respect.  Much,  however, 
depends  upon  habit ;  many  persons  would  lie  awake  for 
hours  if  a  loud  ticking  clock  were  introduced  into  their 
room,  and  to  most  the  noise  of  a  water-mill  would  be 
unbearable  ;  whereas  persons  accustomed  to  these 
sounds  will  find  themselves  unable  to  sleep  when  the 
noises  are  no  longer  present. 

In  some  cases  of  sleeplessness  the  question  arises, 
whether  the  sleep  has  been  earned  ?  Have  the  muscles 
or  the  brain  been  so  exercised  that  sleep  is  demanded 
for  their  restoration  ?  A  person  can  hardly  expect  that 
refreshing  sleep  should  come  at  night-fall  after  passing 
the  day  in  an  easy-chair,  listlessly  turning  over  the 
leaves  of  a  novel  ora  newspaper.    Exercise  is  necessary. 


TREATMENT  OF  SLEEPLESSNESS.  75 


and  not  a  few  persons  who  complain  of  sleeplessness 
and  take  various  drugs  to  make  themselves  drowsy 
must  be  well  aware  that  exercise  of  any  real  kind  is 
almost  unknowai  to  them. 

In  dealing  with  a  case  in  which  sleeplessness  is  a 
prominent  symptom,,  and  in  urgent  need  of  relief, 
every  attempt  should  be  made  to  ascertain  the  cause. 
It  is  too  much  the  fashion  to  give  narcotics  as  a  matter 
of  course;  these  should  never  be  used  unless  other 
means  fail."  Remembering  that  vascular  excitement  is 
the  condition  w^hich  obtains  in  most  cases  of  sleepless- 
ness the  physician  should  trace  this  to  its  real  cause. 
If  it  be  due  to  indigestion^  the  treatment  is  obvious. 
The  state  of  the  stomach  and  bowels  should  be  care- 
fully attended  tOj  and  suitable  diet  and  time  for  meals 
prescribed.  Inquiries  should  be  made  as  to  the  patient's 
occupation,  especially  as  to  whether  sufficient  exercise 
is  taken^  and  the  manner  in  which  the  evenings  are 
spent.  If  it  be  discovered  that  a  somewhat  heavy 
meal  is  taken  late  in  the  evening  by  way  of  dinner^  and 
the  patient  goes  to  rest  with  an  overloaded  stomachy  it 
is  obvious  that  a  decided  alteration  is  required*.  The 
evening  meal  must  be  a-  light  one,  consisting  of  very 
little  meat,  and  taken  three  hours  before  bedtime.     Any 


76  TEJEATMENT  OF  SLSjEP'LFSSNJSSS. 

excess  as  regards  alcohol  or  tobacco  must  be,  of  course^ 
strictly  interdicted. 

In  the  treatment  of  sleeplessness  occurring  in  patients 
of  the  gouty  diathesis  the  regulation  of  the  diet  is  again 
all-important.  It  is  well  to  supply  such  patients  (and, 
indeed,  many  others)  with  printed  diet  rules.  For  some 
time  past  I  have  been  in  the  habit  of  employing  a  set 
of  forms  on  which  the  hours  for  meals  and  the  articles 
that  may  be  taken  and  those  that  must  be  avoided  are 
clearly  specified.  I  am  constantly  meeting  with  such 
cases ;  careful  attention  to  diet  invariably  gives  relief. 
Next  to  diet,  exercise,  fresh  air,  and  attention  to  the 
functions  of  the  skin  and  bowels  are  the  principal  points 
to  be  thought  of.  A  course  of  saline  purgatives,  e.g., 
Carlsbad  salts,  is  often  the  best  remedy  for  gouty  in- 
somnia. Other  purgatives,  as  colocynth  or  rhubarb, 
with  a  little  blue  pill,  are  likewise  suitable,  and  if  these 
remedies  fail  to  relieve  the  sleeplessness  the  bromides 
may  be  tried,  but  their  use  should  not  be  persevered 
with. 

Cases  in  which  sleep  is  prevented  by  anxiety  or 
excitement  are  often  very  difficult  to  deal  with.  The 
cause,  perhaps,  cannot  be  removed,  and  it  is  necessary 
to  relieve  the  symptom.     Hypnotics  of  some  kind  are 


TREATMENT  OF  SLEEPLESSNESS.  77 

indispensable  for  such   cases^  and  the  choice  generally 
lies  between  opium,  or  some  one  of  its  preparations, 
chloral,   and  the   bromides.     Each   of    these    has    its 
drawbacks ;    opium    checks    all    the  secretions    except 
that  of  the  skin  and  produces  constipation   and  dys- 
pepsia.    Chloral  is  apt  to  weaken  the  heart_,  and  when 
taken  regularly  for  any  length  of  time  it  sometimes 
produces  great  depression,  irritability,  and  even  a  suicidal 
tendency.  The  drawbacks  connected  with  the  bromides 
are  of  a  much  less  decided  character.     For  sleepless- 
ness due  to  mental  caused,  a  combination  of  chloral, 
with  bromide  of  potassium  or  ammonium,  often  acts 
satisfactorily.     Fifteen  grains    of  each   of  these  drugs 
should  be  given  at  bedtime,  and  repeated,  if  necessary, 
for  several  nights.     After  two  or  three  doses  have  been 
taken,  and  have  afforded  relief,  it  is  well  to  discontinue 
the  medicines  for  a  night  or  two,  so  as  to  see  whether  a 
fair  amount  of  sleep  can  be  obtained  without  them.    If, 
on  the  other  hand,  the  sleeplessness  continues  in  spite  of 
the  drugs,  either  the  dose  should  be  increased  or  some  pre- 
paration of  opium  should  be  added  to  the  mixture.  One  of 
the  best  is  nepenthe  in  doses  of  fifteen  or  twenty  minims, 
and  a  combination    of  the  three  drugs  sometimes  acts 
better  than  any  one  of  them  separately.    If  constipation 


78  TRJEATMJENT  OF  SLEEPLESSNESS. 

occur^  it  should  be  remedied  by  aloes.  As  in  all  other 
cases  of  sleeplessness^  directions  must  be  given  on  such 
points  as  diet,  exercise,  avoidance  of  all  unnecessary 
excitement,  etc.  Such  measures  as  a  dark  and  quiet 
room,  not  too  hot,  but  raised,  if  necessary,  to  a  suitable 
temperature,  a  comfortable  bed,  and  other  details,  to  be 
found  in  a  subsequent  paragraph,  will  always  repay 
attention. 

The  sleeplessness  which  results  from  cold  or  from 
cold  feet  is  for  the  most  part  easily  relieved.  A  fire  in 
the  bedroom  will  bring  the  temperature  to  the  necessary 
height,  say  from  ^j'^  to  60°,  and  there  are  several  ways 
in  which  the  feet  can  be  kept  warm.  Sleeping  socks, 
hot  water  bottles,  and  wrapping  the  feet  in  a  piece  of 
flannel  are  the  ordinary  means  of  this  description. 
Sponging  the  feet  with  cold  water  and  subsequent 
friction  is  another  useful  remedy.  Sleeplessness  caused 
by  heat  is  best  dealt  with  by  cold  or  tepid  sponging  of 
the  body  before  going  to  bed;  and  cold  applications  to 
the  forehead,  retained  while  the  patient  is  lying  down, 
will  often  induce  sleep  in  hot  weather.  In  some  hot 
countries  sleep  is  often  induced  in  native  children  by 
allowing  a  tiny  stream  of  water  to  fall  upon  the  fore- 
head 'j  under  the  soothing  and  cooling  influence  of  the 


teeatmi:nt  of  sleeplessness.  79 

water  children  will  sleep  placidly  for  hours  while  their 
mothers  are  at  work. 

The  sleeplessness  of  elderly  people  can  generally  be 
relieved  by  the  bromides^  combined  with  henbane.  The 
precaution  as  to  warmth  is  very  necessary  in  these  cases. 
Eczema  is  sometimes  a  very  troublesome  complication, 
especially  as  the .  itching  is  made  worse  by  a  high 
temperature.  Under  these  circumstances  the  resources 
of  the  physician  are  liable  to  be  severely  taxed ;  one 
remedy  after  another  has  to  be  tried  until  the  right  one 
is  met  with.  •  Sponging  the  body  with  vinegar  and 
water  before  going  to  bed  is  sometimes  efficacious ; 
zinc  ointment^  boric  acid  ointment^  and  white  pre- 
cipitate ointment  are  all  likely  to  be  useful.  Sleepless- 
ness in  anaemic  persons  is  best  combated  by  a  liberal 
diet,  ironj  and  stimulants ;  for  the  generality  of  these 
cases  oatmeal  biscuits  with  some  hot  wane  and  water  or 
spirits  and  water  are  the  best  sleeping  draughts. 

*  There  are  a  few  other  points  of  universal  applicability 
in  dealing  with  sleeplessness.  Strong  light  acts  as  a 
mental  excitant  and  checks  sleep ;  on  the  other 
handj  darkness,  especially  when  accompanied  by 
silence,  has  a  calming  effect,  and  disposes  to  sleep. 
Brushing  and   combing  the  hair   has  a  sedative  effect^ 


'So  te]satmi:nt  of  sljeeplessnuss. 

and  is  resorted  to  by  some  patients.  Some  of  the 
popular  measures  recommended  for  inducing  sleep  are 
more  apt  to  produce  the  opposite  result.  Among  these 
may  be  mentioned  the  mental  repetition  of  numbers^  or 
lines  of  poetry^  attempts  at  mental  calculation^  and 
the  picturing  to  the  imagination  of  a  field  of  waving 
corn,  or  of  a  number  of  animals — such  as  sheep — rush- 
ing in  single  file  through  a  gateway.  A  more  efficacious 
plan  is  to  get  out  of  bed  and  drink  a  little  cold  water, 
or  bathe  the  face  and  neck,  or  remain  at  the  bedside 
until  a  sensation  of  chilliness  is  experienced.  An  old- 
fashioned  remedy  for  sleeplessness  was  a  pillow  of 
hops,  on  which  the  patient  placed  his  head.  The  benefit 
said  to  have  been  obtained  from  it  by  George  III.,  for 
whom  it  was  prescribed  by  Dr.  Willis  in  1787,  brought 
it  into  very  general  use.  ^ 


CHAPTER   IV. 

HYSTERIA.  " 


Hysteria,  Definition  of  the  Term — Historical  Notices  and 
Geographical  Distribution — Causes — Age  and  Hereditary 
Predisposition  to  Nervous  Disorders — The  Uterine  Theory 
OF  Hysteria — Local  Irritation  and  the  State  of  the 
General  Health — Exciting  Causes  of  the  Paroxysms — 
Morbid  States  of  System,  as  in  Gout — Symptoms  of  Hysteria, 
their  Great  Variety — Signs  of  Mental  Perversion — Altera- 
tions of  the  Moral  Character — Peculiarities  of  the 
Symptoms — The  Hysterical  Paroxysms — Hystero-Epilepsy, 
Symptoms  and  Peculiar  Features  of  the  Attacks — Other 
Forms  of  Motor  Disorder — Paresis — Permanent  Contrac- 
tion AND  Rigidity  of  Muscles  and  Limbs — Disorders  of 
Sensation,  Hyperesthesia,  the  Clavus  Hystericus  and  Neu- 
ralgia— An.'esthesia,  its  Forms — Disorders  of  the  Special 
Senses — Disorders  of  the  Function  of  Digestion — of  Respi- 
ration— OF  the  Circulation — of  Secretion — The  Urine — 
Course,  Duration,  and  Results  of  Hysteria — Prognosis — 
Diagnosis — Treatment,  Prophylactic,  Curative,  and  Sympto- 
matic— Removal  of  Young  Subjects  from  Home  Influences — 
Attention  to  Uterine  Complaints  and  to  General  Condition 
— Treatment  of  Mental  Disorders — Hygienic  Measures — 
Medicines — Relief  of  Prominent  Symptoms  —  Treatment 
During  the  Paroxysm — of  the  Complications — Metallo- 
Therapeutics  —  Galvanism  and  Faradism  —  The  Weir 
Mitchell  System — Hydropathic  Treatment. 


82  SYSTERIA. 


Hysteria  consists  of  a  group  of  symptoms,  occurring 
mainly  in  females,,  and  indicative  of  functional  dis- 
turbance of  the  nervous  system  in  general.  It  is 
characterized  by  evidences  of  mental  perversion,  and  by 
disorders,  more  or  less  marked  in  different  cases,  of  all 
the  functions  of  the  body.  The  term  ^''hysteria'' 
implies  the  idea  of  a  close  connection  between  the 
symptoms  thus  designated  and  the  uterus ;  but  how- 
ever close  this  relationship  may  be  in  some  cases,  there 
are  many  others  in  which  it  cannot  be  shown  to  exist. 
Moreover,  the  fact  that  symptoms  of  hysteria  are  some- 
times witnessed  in  male  subjects  proves  that  the  oc- 
currence of  the  disorder  is  not  necessarily  dependent 
on  the  state  of  the  organ  from  which  the  term  is 
derived. 

According  to  Dr.  Hirsch,*  hysteria  is  remarkable 
among  the  neuroses  for  its  frequency  and  generality  of 
diffusion  at  all  times  and  in  all  parts  of  the  world.  It 
is  described  in  the  very  oldest  Brahminical  writings 
and  by  the  Greek  and  Arabian  physicians,  some  of 
whom  regarded  it  as  the  effect  of  spasmodic  contrac- 
tions of  the  uterus  or  of  displacement   of  that  organ, 

*  "  Handbook  of  Geographical  and  Historical  Pathology,"  New  Syd. 
Sec.  Transl.,  Vol.  III.,  p.  516. 


GEOGRAFRICAL  DISTRIBUTION  OF  HYSTERIA.    83 

this  latter  condition  being  supposed  to  account  for  the 
sensation  long  known  as  the  ^^  globus  hystericus." 
Others  thought  it  was  due  to  retention  of  the  menstrual 
blood  or  of  the  semen.  These  and  similar  views  pre- 
vailed until  the  beginning  of  the  iSth  century,  when 
the  idea  was  first  propounded  that  hysteria,  like  epilepsy, 
was  an  affection  of  the  brain.  Sydenham  considered 
hysteria  to  be  the  most  frequent  of  all  chronic  diseases, 
and  stated  that,  though  most  common  in  women, 
it  was  sometimes  seen  in  men ;  hence  uterine 
disorders  could  not  be  its  real  cause,  but  its  origin 
must  be  sought  in  an  affection  of  the  nervous  system. 
Later  on  another  English  writer.  Dr.  Whytt,  asserted 
that  hysteria  was  often  dependent  on  uterine  disorder, 
but  might  occur  in  its  absence,  and  that  it  w^as  really 
due  to  "a  too  great  delicacy  and  sensibility  of  the 
nervous  system." 

With  regard  to  its  geographical  distribution,  hysteria 
would  appear  to  be  a  common  disorder  in  many  parts  of 
the  world.  It  is  found  in  the  Arctic  latitudes  of  the 
Eastern  Hemisphere  ;  it  is  said  to  be  common  in  Central 
Europe,  and  especially  frequent  in  the  southern  parts  of 
that  continent.  In  Turkey  it  is  reported  to  be  '^  the 
heritage  of  women  and  the  scourge  of  men.^'     So  far 


84  CAUSES  OF  HYSTERIA. 

as  is  known,  Asiatic  women  are  much  less  liable  to  the 
complaint ;  it  is  very  rare  indeed  among  the  Hindoos. 
On  the  other  hand,  in  parts  of  Africa,  e.g.,  the  Cape,. 
Mauritius,  and  Madagascar,  Egypt  and  Tunis,  hysteria 
is  said  to  be  unusually  common.  In  the  Western  Hemi- 
sphere it  is,  as  might  be  expected,  '^  very  prevalent  among 
women  of  the  upper  classes  in  the  United  States,  par- 
ticularly in  the  South /^  It  is  also  common  in  Mexico^ 
and  Brazil  and  among  the  Creole  women  of  the  West 
Indies. 

Causes.  It  has  been  already  stated  that  hysteria  is 
almost  entirely  confined  to  the  female  sex.  Males  very 
rarely  present  symptoms  that  can  justly  be  described  as 
hysterical,  though  some  French  authors  assert  that  one 
case  of  hysteria  occurs  among  males  to  every  twenty 
among  females !  The  first  symptoms  of  hysteria  are- 
wont  to  appear  at  the  time  of  puberty ;  but  in  not  a 
few  cases  they  show  themselves  even  at  an  earlier  period, 
though  not  in  a  very  marked  form.  In  the  large 
majority  of  hysterical  subjects  the  symptoms  are 
developed  before  the  2^oth  year ;  in  a  smaller  propor- 
tion they  come  on  between  0,0  and  30.  After  the 
latter  age,  and  until  the  menopause,  the  proclivity 
becomes  gradually  lessened.  Symptoms  are  occasionally 


CAUSES  OF  HYSTSRIA.  85 

developed  in  women  during  "the  change  of  Hfe;^'  but 
this  once  passed  immunity  is  the  ahnost  universal  rule. 
Hereditary  predisposition  to  nervous  disorders  plays  a 
■conspicuous  part  in  the  causation  of  hysteria^  and  the 
predisposition  thus  derived  is  too  often  fostered  by 
constant  association  with  the  affected  parent  and  by 
defective  education  and  training.  A  mother  subject  to 
hysteria  is  a  bad  example  to  daughters,  and  is  generally 
incapable  of  adopting  any  measures  calculated  to  lessen 
the  inherited  tendency.  Other  circumstances  often  tend 
to  confirm  the  predisposition.  Sedentary  habits^  idle- 
ness, indulgence  in  sleep,  vicious  practices,  and  that  pre- 
■  mature  development  of  the  emotional  side  of  a  girPs 
nature  which  often  follows  excessive  devotion  to  sensa- 
tional literature  are  potent  factors  of  this  character. 

The  uterine  theory  of  hysteria  has  been  already 
referred  to.  There  is  no  doubt  that  local  disorders  of 
the  genital  organs  often  take  a  considerable  share  in  the 
causation  of  hysteria.  Malpositions  of  the  uterus, 
erosions  or  ulceration  of  the  os  or  cervix,  and  other 
chronic  sources  of  irritation  are  capable  of  producing 
and  perpetuating  hysterical  symptoms,  especially  in  the 
subjects  of  hereditary  predisposition.  The  connection 
is  demonstrated  by  the  fact  that  the  symptoms  often 


86  CAUSES  OF  HYSTERIA. 

subside  after  the  local  disorder  has  been  cured.  The 
relationship  is  still  further  evidenced  by  the  frequency 
with  which  hysterical  attacks  are  wont  to  occur  during 
pregnancy  and  at  the  catamenial  periods.  The  con- 
dition of  the  ovaries  is  also  connected  with  the  disorder. 
In  many  cases  pressure  over  these  organs  causes  severe 
pain  or  even  an  acute  attack.  In  hysterical  males  it  is 
alleged  that  symptoms  may  be  induced  by  compressing 
the  testicles.  Unsatisfied  sexual  desire  has  been  thought 
to  be  a  cause  of  hysteria.  Be  this  as  it  may^  it  is 
certain  that  hysterical  symptoms  are  common  and  severe 
arhong  the  victims  of  sexual  excesses.  In  the  case  of 
women  living  in  a  state  of  celibacy  there  is  often  much 
in  their  surroundings  tending  to  produce  emotional 
disorder  ;  the  want  of  congenial  occupation^  a  feeling  of 
loneliness  and  neglect,  disappointment^  vexations^  and 
anxiety  as  to  the  future^  these  and  many  other  circum- 
stances tend  to  produce  an  unhealthy  state  of  mind 
which  is  a  primary  condition  for  the  development  of 
hysteria. 

Irritation  of  other  parts  besides  the  sexual  organs 
may  induce  symptoms  of  hysteria.  Thus  they  are 
sometimes  noticed  to  occur  after  injuries,  and  to  show 
themselves    most    prominently    in  the   affected     part. 


CAUSES  OF  HYSTERIA.  87 


Hemianaesthesia  has  been  known  to  set  in  after  a  fall  in 
which  one  side  was  slightly  injured  ;  a  bruised  finger  has 
been  followed  by  paralysis  of  the  upper  extremity. 
Neuroses  of  joints,  a  common  symptom  in  hysterical 
subjects,,  are  often  attributable  to  previous  injury. 

The  development  of  hysteria  is  more  or  less  favoured 
by  all  circumstances  tending  to  impair  the  general 
health.  Thus  the  debility  of  convalescence  from  ex- 
hausting diseases,  such  as  fevers,  pneumonia,  etc.,  and 
the  anaemic  state  in  general  predispose  to  attacks. 
Hysterical  symptoms  are  sometimes  witnessed  in 
children,  the  subjects  of  latent  tuberculosis. 

Of  the  exciting  causes  of  the  paroxysms  anything 
capable  of  strongly  impressing  the  nervous  system  is 
by  far  the  most  active.  The  first  attack  is  liable  to  be 
induced  by  mental  shocks  of  various  kinds,  e.g.,  terror, 
anger,  grief,  or  even  surprise,  and  when  the  hysterical 
condition  has  been  established,  slight  causes  of  this  kind 
will  suflfice  to  provoke  a  paroxysm.  The  imitative 
impulse  is  another  powerful  exciting  cause  ;  the  sight  of 
one  woman  in  hysterical  convulsions  has  often  induced 
similar  paroxysms  in  others  who  had  previously  shown 
no  signs  of  the  disorder.  Epidemics  of  hysteria  form 
one  of  the  most  curious  chapters  in  geographical  and 


SYMPTOMS  OF  HYSTJERIA. 


historical  pathology.  With  regard  to  various  morbid 
states  of  the  system_,  as  causes  of  the  affection,  there  is 
much  reason  for  believing  that  hysterical  symptoms  in 
middle-aged  women  are  sometimes  referable  to  the 
presence  of  the  gouty  diathesis,  and  are  to  be  classed 
among  the  irregular  gouty  manifestations.  It  is  easily 
conceivable  that  the  accumulation  of  sodium-urate  in 
the  blood,  acting  as  an  irritant  to  the  nervous  system, 
should  give  rise  to  attacks  in  those  in  any  way  pre- 
disposed to  them. 

Symptoms.  It  is  well  nigh  impossible  to  give  a  suc- 
cinct and  connected  account  of  the  protean  manifesta- 
tions of  hysteria.  The  most  striking  symptoms  occur 
simultaneously  or  in  quick  succession,  constituting  the 
hysterical  paroxysm ;  but  there  are  various  other  phe- 
nomena incident  to  the  complaint,  many  of  them  closely 
simulating  real  and  serious  affections.  In  typical  cases 
signs  of  mental  perversion  are  usually  the  first  to 
appear,  and  these  are  followed  by  paroxysms  and  other 
motor,  sensory,  and  sympathetic  disturbances  of  the 
most  varied  kind,  and  grouped  together  in  every  con- 
ceivable manner.  The  greatest  possible  differences 
exist  in  the  symptoms  presented  by  hysterical  patients; 
in  some  they  are  so  slight  as  to  be  scarcely  recognizable,' 


SYMPTOMS  OF-EYSTERIA.  89 

m  others  the  convulsive  paroxysms  are  of  the  most 
violent  character^  and  various  other  phenomena  are 
scarcely  less  marked.  Moreover^  the  same  patient  may 
exhibit  very  different  symptoms  at  different  times.  In 
order  to  give  as  clear  an  account  as  possible,  I  propose 
to  consider  first  the  signs  of  mental  perversion  so 
common  in  hysteria ;  secondly^  the  paroxysmal  attacks 
and  other  motor  disorders  ;  and  thirdly,,  the  symptoms 
indicating  disturbances  of  sensation^  digestion,  respira- 
tion, circulation,  and  secretion. 

I.  The  signs  of  mental  perversion  vary  in  kind  and 
degree,  but  the  majority  of  them  point  to  a  disordered 
state  of  the  emotions.  In  the  most  common  form  of 
the  complaint  there  is  at  the  commencement  an 
exaggeration  of  ordinary  emotional  excitement ;  for 
example,  laughter  and  crying  are  induced  by  very  slight 
causes,  are  repressed  with  difficulty  and  recur  on  the 
slightest  provocation.  Lowness  of  spirits  is  another 
common  symptom.  Without  any  assignable  reason, 
or  for  one  which  is  totally  inadequate,  the  patient  will 
remain  for  hours  or  even  for  days  in  a  depressed, 
listless  state,  which  perhaps  suddenly  passes  off,  to  be 
succeeded  by  the  normal  condition,  or  by  symptoms  the 
reverse  of  those  so  recently  exhibited.    Any  peculiarities 


90  SYMPTOMS  OF  HYSTJEEIA. 

of  temper  §.re  apt  to  become  emphasized ;  impatience, 
capriciousnesSj    and  irritability    make   themselves    un- 
pleasantly   manifest.     The     slightest    cause    may    be 
sufficient  to  excite  a  paroxysm  of  anger,  which  cannot 
be  allayed,  and  soon  passes    into  a  convulsive  attack. 
Alterations   of  the  moral  character  are  very  common, 
and  are  among  the  most    painful  features  of  the  com- 
plaint.    Some  patients  become  listless  and  indifferent, 
caring  little  or  nothing  for  what  is  going  on  around 
them  ;   others  become  inquisitive,  fussy,  and  morbidly 
anxious  for  others.     More  often,  however,  the  patient's 
attention  is  concentrated  upon  herself;  she  makes  the 
most  of  any  little  ailments  or  discomforts,  recapitulates 
them  to  her  friends,  and  loses  her  temper  or  falls  into  a 
paroxysm  if  anyone  ventures  to  question  the  accuracy 
of  her  statements.     Whims   of  the  most  varied  kind 
are  invented  from  time  to   time ;  those  who  point  out 
their  absurdity  are  regarded  as    enemies.     By   degrees 
the  patient  may  get  into  such  a  state  of  obstinacy  as  to 
cling  with  the  utmost    firmness  to  any  idea  that  she 
has  formed  with  regard  to  her  own  condition.  Attempts 
to  convince  her  of  her  error  only  make  her  worse  ;  if  she 
can  find  a  sympathetic  listener,  there  is  no  limit  to  her 
delight.    It  is  obvious  that  these  and  similar  manifesta- 


STMPTOJ^S  OF  HYSTERIA.  91 

tions  approach,  if  they  do  not  pass,  '^  the  borderlands  of 
msanity;"  and  it  is  often  very  difficult  to  determine 
whether  the  latter  condition  has  been  reached. 

In  a  large  number  of  hysterical  subjects  a  marked 
tendency  to  deceive  others  is  one  of  the  most  pro- 
minent features,  and  stories  of  the  most  extraordinary 
character  are  invented  by  the  patients  for  this  purpose. 
The  state  of  the  urinary  and  genital  organs  is  a  very 
common  topic  for  their  complaints ;  retention  or  even 
suppression  of  urine  is  often  asserted  to  exist;  frag- 
ments are  shown,  alleged  to  have  been  passed  from  the 
bladder,  or  urine  is  declared  to  have  been  ejected  from 
the  stomach.  Some  hysterical  patients  take  great  pains 
to  injure  themselves  in  various  ways,  and  profess  the 
most  complete  ignorance  of  the  cause  of  a  wound  thus 
made.  As  to  the  motives  which  induce  them  to  per- 
form these  acts  of  deception,  some  patients  wish  to 
become  objects  of  notoriety,  to  have  their  cases  talked 
about  by  as  large  a  circle  as  possible;  others  desire  to 
attract  commiseration  and  sympathy,  and  others,  again, 
are  influenced  by  motives  of  pruriency. 

There  are  still  other  modes  in  which  the  mental 
disorder  is  exhibited.  Sometimes  the  patients  are 
obstinately  silent,  refuse  to  answer  the  simplest  ques- 


92  TEE  HYSTERIC AL' PAROXYSM. 

tions,  and  shut  themselves  up  in  their  rooms  so  as  to 
be  able  to  indulge  their  propensity.  The  silence  may 
be  succeeded  by  a  fit  of  volubility^  in  which  the 
strangest  and  most  improbable  stories  are  told.  When 
this  volubility  is  a  prominent  feature  in  the  complaint, 
those  who  are  compelled  to  associate  with  the  patient 
are  in  a  most  unenviable  position. 

The  symptoms  as  above  described  often  display  this 
peculiarity,  that  they  come  on  at  intervals  between 
which  the  condition  of  the  patient  appears  to  be  per- 
fectly rational  and  normal.  In  some  cases  the  patients 
know  when  the  symptoms  are  threatening^  and  assert 
that  they  make  a  prodigious  effort  to  check  their  onset. 
Partial  success  is  sometimes  attained  in  this  direction, 
but  the  power  of  self-control  generally  becomes  less 
and  less,  while  that  of  the  emotions  steadily  increases 
until  the  patient  is  unable  to  resist  even  the  slightest 
impulse.  When  this  stage  is  reached,  the  patient  can 
scarcely  be  regarded  as  responsible  for  her  actions. 

II.  Though  a  greater  or  less  degree  of  mental  perver- 
;sion  is  to  be  found  in  most  hysterical  subjects,  there  is 
a  somewhat  numerous  class  in  which  such  symptoms 
never  attract  much  attention,  as  compared  with  those 
which   constitute   the   hysterical    paroxysm.     This    is 


THE  HYSTERICAL  PAROXYSM.  9.^ 


characterized  by  violent  convulsions  of  a  tetanic  or 
epileptic  character,  induced  by  various  kinds  of  stimuli, 
and  especially  by  anything  which  appeals  to  the 
emotions.  These  paroxysms  are  wont  to  occur  at 
irregular  intervals ;  in  some  patients  they  are  the  chief, 
if  not  the  only,  signs  of  disorder;  in  others^  they  are 
merely  the  prominent  features  of  the  protean  com- 
plaint. 

The  paroxysm  may  come  on  suddenly,  without  any 
premonitory  symptoms  j  or  it  may  be  preceded  by 
some  of  the  symptoms  of  mental  disorder,  already  in- 
dicated, or  by  various  distressing  sensations,  e.g.,  pres- 
sure at  the  epigastrium  or  in  the  chest,  or  a  feeling  as 
if  a  ball  were  rising  from  the  abdomen  to  the  throat. 
Then  perhaps  a  vacant  stare,  or  rolling  movements  of 
the  eyes,  lasting  for  a  few  seconds,  are  followed  by  a 
loud  scream;  the  patient  falls  to  the  ground,  or  finds 
her  way  to  a  sofa,  throws  her  limbs  about  and  twists 
her  body  in  various  directions,  sometimes  tries  to  tear 
her  hair  and  strikes  herself,  though  without  doing  any 
serious  injury.  "While  these  movements  are  going  on 
the  patient  often  shrieks  or  cries  or  laughs,  or  perhaps 
raves  about  some  one  whose  presence  or  memory  has 
excited   the   paroxysm.     After   lasting   for   a   variable 


94  TSi:  HYSTERICAL  PAROXYSM, 

period  (in  some  cases  only  a  few  minutes^  in  others 
half-an-hour  or  more)  the  convulsions  subside^  a  flood 
of  tears,  a  fit  of  laughter,  or  a  confused  mixture  of 
laughing  and  crying  affords  the  necessary  relief,  and 
the  patient  is  gradually  restored  to  her  usual  condition. 
After  long-continued  and  severe  convulsions  the 
patient  is  apt  to  fall  into  a  lethargic  state,  as  if  quite 
exhausted,  or  even  to  go  to  sleep  for  some  hours.  The 
convulsions  present  innumerable  variations  j  sometimes 
only  an  arm  or  leg  is  flexed  or  extended  at  irregular 
intervals  ;  sometimes  every  muscle  of  the  body  appears 
to  be  in  action,  and  the  united  force  of  several  persons 
is  insufficient  to  restrain  the  patient.  In  some  cases 
the  convulsions  alternate  v^ith,  or  are  replaced  by  tonic 
spasms ;  one  or  more  limbs  are  firmly  contracted,  or 
the  body  assumes  the  form  of  an  arch  as  in  cases  of 
poisoning  by  strychnine.  In  severe  and  exceptional 
cases  (which  belong  to  the  category  of  hystero-epilepsy) 
the  consciousness  is  entirely-  lost  during  the  height  of 
the  paroxysm ;  but  more  often  the  patient  is,  to  some 
extent  at  least,  aware  of  what  is  going  on,  her  appear- 
ance showing  that  she  is  alive  to  the  absurdity  of  her 
performances. 

The    paroxysms    usually    occur    at    very    irregular 


ETSTER  O-EPILEPSY. 


95 


intervals ;  they  may  recur  daily  or  not  until  weeks  or 
even  months  have  elapsed.  Their  frequency  depends 
greatly  upon  the  surroundings  of  the  patient  and  the 
condition  of  her  nervous  system.  In  some  cases  the 
attacks  come  on  at  the  monthly  periods,  and  they  are 
usually  most  severe  at  these  times.  It  is  worthy  of 
note,  as  showing  the  resemblance  between  hysteria  and 
other  forms  of  nervous  disorder,  that  the  patient  often 
feels  decidedly  better  after  a  severe  paroxysm,  the  ex- 
plosion apparently  relieving  the  overburdened  nervous 
system. 

The  term  hystero-epilepsy  is  applied  to  designate  severe 
convulsive  attacks  exactly  similar  to  the  paroxysms  of 
epilepsy,  but  occurring  in  hysterical  subjects,  and  to  be 
classed  among  the  phenomena  of  hysteria.  The  con- 
dition has  been  regarded  as  a  combination  of  the  two 
disorders,  sometimes  the  one,  and  sometimes  the  other 
assuming  the  greater  prominence.  The  symptoms  are, 
however,  best  interpreted  by  adopting  Charcot's  view, 
that  in  these  cases  hysteria  alone,  is  present,  and  that  it 
takes  on  the  semblance  of  epilepsy. 

A  typical  attack  of  hystero-epilepsy  is  generally  pre- 
ceded for  some  days  by  various  uncomfortable  feelings, 
such  as  loss  of  appetite,  nausea  or  vomiting,  headache," 


96  SYSTES  0-EFIZJEFS  T. 

etc.  Some  patients  are  unusually  quiet  and  taciturn^ 
others  excited  and  noisy.  If  hemianaesthesia  be 
present,  it  becomes  more  marked  and  is  apt  to  spread 
to  the  other  side  of  the  body.  Finally  the  aura  is  felt^ 
beginning  in  the  epigastrium  or  in  the  iliac  regions ;  it 
lasts  for  some  time,  and  the  patient  is  therefore  generally 
able  to  seek  a  place  of  safety  before  the  convulsions 
come  on.  These  begin  as  in  true  epilepsy  ;  the  patient 
screams,  turns  pale,  becomes  unconscious  and  falls  if 
standing.  The  body  and  limbs  become  perfectly  rigid. 
In  some  cases  the  body  is  arched  upwards  like  a  bridge,, 
and  rests  only  upon  the  feet  and  head.  The  rigidity, 
according  to  Charcot,  is  seldom  followed  by  the  clonic 
convulsions,  not  very  extensive,  but  most  marked  on 
one  side  of  the  body,  as  in  true  epilepsy.  On  the  other 
hand,  the  limbs  and  the  entire  body  are  violently  con- 
torted j  the  patient  makes  the  strangest  gesticulations  and 
assumes  extraordinary  postures.  Delirium  then  super- 
venes, during  which  the  patient  has  horrible  visions,  as 
of  animals  or  thieves  attacking  her,  of  fire  and  the  like. 
She  raves  furiously,  or  shouts,  or  screams  as  if  in 
imminent  danger.  The  termination  of  the  attack  is 
ushered  in  by  tears  and  laughter,  and  after  these  have 
subsided  the  patient  is  apt  to  remain  for  some  time  in  a 


SYSTERO-EPILEPSY.  97 


State  of  melancholia,  with  hallucinations,  and  some- 
times painful  contractures  of  various  joints.  During 
the  convulsions  the  tongue  may  be  bitten,  and  bloody 
foam  may,  therefore,  appear  at  the  mouth.  The 
paroxysm  lasts  on  an  average  about  a  quarter  of  an 
hour;  it  may  recur  again  and  again  at  short  intervals, 
the  attacks  in  this  way  extending  over  several  hours  or 
ev^en  days. 

According  to  Charcot,  the  paroxysms  are  distinguish- 
able from  true  epilepsy  by  the  fact  that  they  can  be 
modified  or  sometimes  even  arrested  by  compression  of 
the  ovary.  Moreover,  in  hystero-epilepsy  the  tempera- 
ture never  lises  above  101*3°  F. ;  whereas,  after  a  series 
of  true  epileptic  fits  a  height  of  105*8°  F.  may  be 
attained,  and  may  continue  for  some  time.  There  is 
another  and  a  most  important  difference  between  the  two 
affections ;  attacks  of  hystero-epilepsy  may  follow  each 
other  in  rapid  succession  at  the  rate  of  a  hundred  or 
more  in  the  twenty-four  hours,  and  yet  the  patient's 
general  state  may  be  but  little  affected.  Oft-recurring 
paroxysms  of  true  epilepsy  with  the  accompanying  high 
temperature  would  place  the  sufferer  in  a  very  critical 
position.  It  is  only  in  very  rare  instances  that  death 
has  occurred  as  a  result  of  hystero-epilepsy. 

7 


98  SYSTERICAL  PARALYSIS. 

III.  In  addition  to  the  convulsive  movements,  various 
other  forms  of  motor  disturbance  are  liable  to  occur 
in  hysterical  subjects.  Paresis  of  the  extremities  is  a 
somewhat  frequent  phenomenon,  and  presents  many 
degrees  of  intensity.  In  some  cases  there  is  only  a 
feeling  of  weight  and  immobility,  but  this  suffices  to 
make  the  patient  believe  that  she  has  lost  the  use  of  her 
limbs.  Such  patients  may  remain  in  bed  or  on  a  sofa 
for  months  or  years,  or  until  some  startling  incident,  or 
a  physician,  who  understands  the  nature  of  the  case, 
restores  the  powers  of  motion.  In  other  cases  the 
motor  power  is  slightly  diminished,  while-  in  a  third 
class  it  is  very  considerably  reduced  ;  the  patient  may  be 
able  to  move  the  legs  while  lying  in  bed,  but  can  neither 
stand  nor  walk.  Complete  paralysis  is  very  rare  indeed, 
except  in  connection  with  secondary  changes  in  the 
cord. 

In  cases  of  hysterical  paralysis  the  electrical  excita- 
bility of  the  muscles  and  nerves  remains  undiminished ; 
but  the  electro-cutaneous  and  the  electro-muscular  sensi- 
bility are  generally  more  or  less  reduced.  Cutaneous 
anaesthesia  is  usually  associated  with  paralysis,  and  is 
apt  to  become  converted  into  the  opposite  condition 
after  the  application  of  the  interrupted  current.     Other 


HYSTERICAL  PARALYSIS.  99 

peculiarities  are  connected  with  hysterical  paralysis; 
rapid  improvement  sometimes  takes  place,  to  be  followed 
sooner  or  later  by  a  return  to  the  former  condition. 
Very  slight  causes,  especially  those  of  an  emotional 
character,  are  sufficient  to  increase  the  weakness ;  a 
woman  able  to  walk  with  comparative  ease  may  be 
suddenly  seized  with  paralysis  which  lasts  for  days  or 
weeks,  and  then  as  suddenly  passes  off.  In  some  cases 
the  paralysis  changes  its  seat ;  first  the  arm,  then  the 
leg  suffers,  or  weakness  on  the  right  side  is  followed  by 
paralysis  of  the  left.  Hemiplegia  and  paraplegia  are  the 
most  common  forms;  the  upper  extremities  are  less 
often  affected.  Paralysis  of  some  of  the  laryngeal 
muscles  is  not  uncommon;  it  gives  rise  to  aphonia, 
which  may  come  on  suddenly,  last  for  a  time,  and  then 
subside. 

These  attacks  of  paralysis  occur  in  some  cases  after 
the  hysterical  paroxysms,  but  in  others  they  supervene 
independently  of  any  marked  explosions.  In  the  latter 
class  the  most  common  immediate  cause  is  sudden 
shock,  or  a  fit  of  anger,  or  anything  that  appeals  to  the 
emotional  susceptibilities  of  the  patient.  Violent 
muscular  exertion  has  been  known  to  be  followed  by 
paralysis,  and  in  other  cases  this  latter  symptom  has 


loo  SYSTERICAL  CONTRACTION. 

come  on  after  the  sudden  subsidence  of  various 
hysterical  manifestations.  Hysterical  hemiplegia  when 
rapidly  developed  closely  simulates  the  result  of  cerebral 
haemorrhage;  but  differs  from  it  in  the  fact  that  con- 
sciousness is  preserved  and  neither  the  tongue  nor  the 
face  is  affected.  Rigidity  is  also  a  common  symptom 
of  the  functional  disorder.  The  onset  of  paralysis  is 
by  no  means  always  sudden  ;  in  not  a  few  cases  it 
seems  to  grow,  as  it  were^  out  of  ordinary  muscular 
weakness.  Nothing  definite  can  be  said  as  to  the 
duration  of  these  paralyses ;  they  may  go  on  for  months,, 
or  years,  or  even  for  life ;  and  recovery  may  take  place 
suddenly  or  very  gradually.  Complete  restoration  is 
the  rule,  but  in  cases  of  long  standing  the  wasting  of 
the  muscles  from  disuse  may  be  very  great,  and  de- 
generation may  become  developed.  Under  such  cir- 
cumstances perfect  recovery  of  the  use  of  the  limbs 
cannot  be  anticipated. 

Permanent  contraction  and  rigidity  of  muscles  and 
limbs  are  not  unfrequent  in  hysterical  subjects,  and 
may  either  supervene  upon  paralytic  conditions  or  may 
occur  independently  of  them.  The  rigidity,  in  some 
cases,  affects  one  side  of  the  body ;  in  others,  the  legs 
are  fixed  in  various  positions ;  while  in  a  third  class  one 


HYSTERICAL  CONTRACTION.  loi 

or  more  muscles  of  the  face,  neck,  or  extremities  are 
firmly  contracted.  The  distortions  of  the  foot  are  apt 
to  simulate  the  various  forms  of  talipes.  These  con- 
tractions are  not  always  spontaneous  ;  they  sometimes 
follow  slight  injuries  to  the  part.  Hysterical  contrac- 
tions of  single  joints  are  often  very  troublesome  to  deal 
with.  The  knee  is  most  liable  to  be  thus  affected,  and 
next  in  order  of  frequency  come  the  hip-joint,  the  wrist_, 
the  foot,  and  the  shoulder.  In  some  cases  the  contrac- 
tion takes  place  suddenly  ;  it  is  always  attended  with 
severe  pain,  which  according  to  the  patient's  description 
closely  resembles  that  of  severe  inflammation  of  a  joint. 
The  suffering,  however,  does  not  prevent  sleep ;  it  is, 
moreover,  not  increased  by  firm  pressure,  though  a 
slight  touch  may  be  described  as  causing  intense  agony. 
The  ordinary  signs  of  inflammation  of  a  joint,  e,g.j 
heat,  redness,  and  swelling,  are  altogether  absent.  The 
joint  remains  immovably  fixed ;  the  patient  asserts  that 
she  cannot  alter  its  position,  and  she  resists  any 
attempt  to  do  so  on  the  part  of  the  nurse  or  physician. 
When  the  patient  is  placed  under  the  influence  of  an 
anaesthetic  the  contraction  disappears,  but  the  limb 
returns  to  its  old  position  when  consciousness  is  re- 
gained.    These  contractions  may   last  for  months  or 


I02  BISOEBEES  OF  SENSATION. 

even  years,  and  then  suddenly  subside  in  a  manner 
apparently  spontaneous.  Excitement  of  various  kinds 
has  beeii  known  to  cure  these  patients.  In  some  cases 
the  disappearance  is  final ;  in  others  the  contraction 
recurs. 

IV.  Disorders  of  sensation  are  among  the  most 
important  phenomena  of  hysteria,  and  appear  in  two 
principal  forms  of  varying  degrees — [a)  hyperaesthesia, 
and  {h)  anaesthesia.  The  hypersesthesia  may  show 
itself  in  almost  any  part  of  the  body,  but  some  portions, 
e.g. J  the  hypogastric,  iliac,  and  epigastric  regions,  are 
especially  liable  to  be  thus  affected.  Many  hysterical 
patients  complain  of  a  dull,  aching  pain  in  the  hypo- 
gastrium,  and  in  one  or  both  iliac  regions,  increased  by 
slight  pressure,  but  sometimes  diminished  or  abolished 
when  pressure  is  firmly  and  steadily  applied.  The  seat 
of  this  sensation  may  be  either  in  the  abdominal 
muscles  or  in  the  ovaries.  Pain  referable  to  the  latter 
organs  may  constitute  the  principal  complaint  of  an 
hysterical  subject,  and  in  such  cases  even  the  slightest 
touch  may  provoke  the  severest  paroxysms.  The 
epigastrium  is  likewise  often  the  seat  of  painful  sen- 
sations, localized  in  the  skin,  abdominal  muscles  or 
stomach  ;  pressure  aggravates  the  pain  and  may  pro- 


THE  CLAVUS  HYSTERICUS.  103 

duce  hysterical  paroxysms.  Severe  pain  in  the  stomach 
is  generally  accompanied  by  such  other  symptoms  as 
vomiting,  loss  of  appetite,  or  aversion  for  ordinary 
food,  and  in  some  cases  the  condition  becomes  so 
severe  as  to  give  rise  to  suspicion  of  gastric  ulcer. 
Colic  is  another  abdominal  ■  affection  frequent  in 
hysterical  subjects;  the  accumulation  of  gas  in  the 
intestines  is  sometimes  enormous. 

Of  the  pains  and  aches  which  beset  hysterical  subjects, 
a  form  of  headache  is  one  of  the  most  common.  It  is 
well  known  under  the  name  of  clavus  hystericus.  The 
pain  is  fixed  in  one  spot,  generally  over  the  eye;  it  is 
described  by  the  patient  as  though  a  red-hot  nail  were 
being  driven  into  the  head,  and  there  is  sometimes 
increased  temperature  around  the  painful  spot.  In  other 
cases  the  sensation  is  said  to  be  that  of  intense  cold  ; 
in  others,  again,  the  pain  is  diffused  over  the  head,  or 
takes  the  form  of  hemicrania.  Equally  common  as  the 
headache  are  pain  and  tenderness  in  the  spinal  column; 
the  group  of  symptoms  known  as  spinal  irritation  is, 
indeed,  most  fully  developed  in  hysterical  subjects. 
Pains  in  various  muscles  are  of  frequent  occurrence, 
the  sensation  not  following  the  course  of  the  nerves,  but 
diffused   among  the    muscular   fibres.     Every  form  of 


I04  SYSTJEEICAL  HTPER^STHJESIA. 

pain  is  increased  when  the  patient^s  attention  is  directed 
to  the  part. 

The  hyperaesthesia  is  sometimes  quite  superficial, 
involving  the  skin  alone,  and  either  extending  over  lar^e 
areas  or  confined  to  small  patches.  In  the  former  case 
the  weight  of  the  clothes  may  be  pronounced  un- 
bearable. The  condition  termed  ancesthesia  dolorosa  is 
sometimes  noticed  in  these  patients ;  the  sense  of  touch 
is  abolished,  that  of  pain  considerably  heightened.  The 
external  organs  of  generation  are  apt  to  be  very  sensitive, 
but  the  skin  of  the  breast  is  the  most  common  seat  of 
the  cutaneous  hyperaesthesia.  This,  in  some  cases,  is 
so  severe  and  obstinate  as  to  give  rise  to  suspicions  of 
cancer;  especially  when,  as  sometimes  happens,  small 
hard  nodules  are  discoverable  in  the  gland.  Neuralgic 
pains  of  all  kinds  are  very  frequent  in  hysterical 
subjects;  the  intercostal  spaces  and  the  joints  being  the 
parts  most  often  affected. 

The  hyperaesthesia  not  unfrequently  affects  the 
organs  of  special  sense;  the  patient  complains  that 
she  cannot  bear  an  ordinary  amount  of  light,  and  that 
she  is  distressed  by  the  slightest  sound.  There  is,  of 
course,  often  much  exaggeration  in  these  and  similar 
statements  ;  the  auditory  nerves  of  the  patient  are  never 
inconvenienced  by  the  noises  she  herself  makes. 


HYSTERICAL  ANESTHESIA.  105 

The  opposite  condition  of  anaesthesia  has  attracted 
■considerable  attention  of  late  years ;  it  has  been  found 
to  be  one  of  the  most  common  symptoms  of  hysteria. 
It  may  affect  only  the  skin  and  mucous  membranes, 
but  in  most  cases  the  muscles  are  also  involved. 
Hemianaesthesia  is  the  most  common  form^  and  the 
left  side  is  more  frequently  affected  than  the  right.  The 
symptoms  closely  resemble  those  due  to  cerebral  haemor- 
rhage; sight,  hearing,  taste,  and  smell  are  unilaterally 
"involved.  In  nearly  all  these  cases  the  sense  of  pain  is 
lessened,  or  even  abolished,  and  less  frequently  the 
sense  of  temperature  is  similarly  disturbed.  There  is  no 
doubt  as  to  the  reality  of  the  loss  ;  the  skin  may  be 
pricked,  or  pinched,  or  heat  mav  be  applied  to  it  without 
the  patient's  knowledge,  provided  that  her  eyes  are 
covered.  The  anaesthesia  usually  comes  on  after  a 
paroxysm ;  it  may  last  only  a  few  hours,  or  may 
continue  for  weeks  or  months.  The  temperature  of 
the  anaesthetic  portions  is  always  lowered,  and  the  skin 
is  usually  whiter  than  natural.  The  loss  of  sensation 
is  sometimes  confined  to  a  few  small  areas,  and  may 
then  be  easily  overlooked.  The  organs  of  special  sense 
are  occasionally  implicated  in  these  cases  of  anaesthesia; 
thus,  various  derangements  of  sight,  hearing,  smell, 
and  taste  are  sometimes  noticeable.     Of  the  disorders 


io6  DIS0Et)BR8  OF  DIGESTION. 

of  vision,  intermittent  colour-blindness^  either  complete 
or  incomplete^  is  the  most  remarkable.  Other  patients- 
assert  that  articles  of  food,  well  known  to  be  sapid,  are 
tasteless  or  the  converse ;  others,  again,  that  they  are 
unable  to  distinguish  odours.  Subjective  gustatory  and 
olfactory  sensations  are  sometimes  complained  of» 
Deafness  is  less  common,  but  tinnitus  aurium  and 
other  subjective  auditory  sensations  are  seldom  absent 
in  well-marked  cases  of  hysteria. 

V.  Disorders  of  the  function  of  digestion  are  very 
common  in  hysterical  subjects,  and  assume  various 
forms.  The  symptom  known  as  the  globus  hystericus 
is  probably  due  to  spasmodic  contraction  of  the  oeso- 
phagus and  intestines.  The  patients  are  wont  to  state 
that  they  feel,  as  it  were,  a  ball  rising  from  the  epigas- 
trium toward  the  throat,  where  it  remains,  and  causes 
a  distressing  sensation  as  if  a  foreign  body  were 
actually  there,  or  as  though  the  throat  were  compressed 
by  a  cord  or  by  fingers.  Some  patients  assert  that 
they  are  unable  to  swallow,  and  this  inability  may 
continue  until  symptoms  of  inanition  become  pro- 
minent. The  stomach  is  liable  to  show  various  indica- 
tions of  disorder.  Obstinate  longing  for  strange  articles 
of  food,  loss  of  appetite,  flatulence,  pain,  and  vomiting, 


DISORBEES  OF  DIGESTION.  107 

sometimes  excessive,  and  continuing  for  lengthened 
periods,  are  among  the  most  prominent  of  these 
symptoms.  The  vomiting,  which  is  due  to  spasmodic 
contraction  of  the  muscles  of  the  stomach  and  oesopha- 
gus, occurs  in  severe  cases  every  time  food  is  taken,  and 
the  efforts  continue  even  when  the  stomach  is  com- 
pletely emptied.  It  is  often  a  matter  for  surprise  that 
these  patients,  ejecting  nearly  all  the  food  they  take, 
should  yet  appear  to  be  well-nourished,  or  at  all  events 
show  no  marked  signs  of  wasting.  The  explanation, 
however,  is  supplied  by  the  facts  that  little  or  no 
exercise  is  taken,  metabolism  goes  on  very  slowly,  and 
the  contents  of  the  bowels  are  retained  for  considerable 
periods.  This  explanation  will  also  serve  to  account  for 
those  cases  in  which  vomiting  is  absent,  but  the 
amount  of  food  actually  taken  seems  insufficient  to 
support  life.  As  a  matter  of  course  the  statements  of  the 
patients  with  regard  to  their  food  can  rarely  be  depended 
upon;  the  tendency  to  deceive  is  often  manifested 
in  this  particular.  The  stories  of  complete  and  pro- 
longed fasting  have  been  proved  to  be  utter  fabrications ; 
the  patients  may  stoutly  refuse  to  take  food,  but  they 
always  manage  to  find  some  means  of  obtaining  it. 
Besides  the  constipation,  other  symptoms  of  abdominal 


io8  DISORBJEES  OF  RESPIRATION. 

disorder  are  collections  of  gases  in  the  intestines^  and 
colicky  pains.  The  distension  is  sometimes  enormous, 
and  such  as  to  resemble  pregnancy  and  various  tumours, 
and  the  rumbling  noises,  which  the  patient  is  unable  to 
check,  greatly  add  to  her  discomfort. 

VI.     Disorders  of  respiration  are  less  frequent  than 
those  of  digestion,  but  some  of  them  are  occasionally 
prominent.     One  of  the  most   troublesome  is  a  dry, 
hard  cough,  which  is  apt  to  worry  the  patient  all   day, 
but  fortunately  ceases  at  night.     In  not  a  few   cases 
this  cough  gives  rise  to  the  suspicion  of  phthisis,  in 
which,  however,    the   nights    are    usually   the    worst. 
Painful  feelings  in  the  larynx  are  not  uncommon  ;  and 
the  voice  may  be  quite  suppressed  or  so  modified  as  to 
be  unrecognizable.     Uncontrollable  hiccough  is  some- 
times   a   very  prominent   and    disagreeable    symptom, 
especially  when  the  patient  voluntarily  adds  to  the  ex- 
plosive noises.     Laboured  breathing,  yawning,  sneez- 
ing, and  sighing  are  other  symptoms  of  this  character, 
and  in  some  cases  precede  the  convulsive  paroxysms. 

VII.  Symptoms  of  disorder  of  the  circulation  are 
always  met  with  in  hysterical  subjects.  More  or  less 
violent  palpitation  is  very  frequent,  is  induced  by  very 
slight  causes,  and  may   last  for  hours   or  even   days. 


DISORDERS  OF  CIRCULATION.  lo^ 

The  heart's  action  is  sometimes  irregular,  sometimes 
attended  with  severe  neuralgic  pain  ;  in  anaemic  cases 
a  bellows  murmur  is  frequently  audible.  Epigastric 
pulsation  is  an  occasional  symptom,  and  one  which 
greatly  alarms  the  patient.  The  pulse  is  subject  to 
many  variations ;  but  is  usually  more  frequent  than 
natural ;  the  state  of  the  cutaneous  circulation  changes 
rapidly  from  time  to  time,  the  skin  being  sometimes 
pale,  and  sometimes  turgid  with  blood.  The  abnormal 
excitability  of  the  vaso-motor  centres  is  shown  by  other 
symptoms,  such  as  marked  coldness  of  the  feet  and 
hands,  which  are  often  covered  wath  a  copious  per- 
spiration ;  a  sensation  of  heat  over  the  head,  particularly 
along  the  course  of  the  sagittal  suture,  and  accompanied 
by  real  elevation  of  temperature.  In  chronic  cases  of 
hysteria  the  face  is  often  the  seat  of  various  eruptions. 
When  anaesthesia  exists,  the  affected  parts  are  apt  to 
be  cold  and  anemic.  Under  an  opposite  condition, 
patches  of  congestion  sometimes  give  rise  to  haemor- 
rhage not  only  from  the  skin,  but  also  from  internal 
organs.  Such  haemorrhage,  e.g.,  from  the  stomach,  is 
to  be  regarded  as  vicarious  when  it  occurs  at  the 
menstrual  periods.  Blood  is  sometimes  discharged 
from  the  bowels  ;  but  the  patient's  account  of  symptoms 
of  this  character  is  always  to  be  received  with  caution. 


no  DISOSDi:SS  OF  SECSETION. 

VIII.  Various  disorders  of  secretion  are  common 
phenomena  in  hysterical  subjects,  and  among  these, 
functional  derangements  of  the  urinarv  oroans  are  often 
prominent.  The  discharge  of  a  large  quantity  of  pale 
urine  generally  takes  place  after  a  paroxysm,  and  in 
some  patients  after  excitement  of  any  kind.  On  the 
other  hand,  the  secretion  may  be  dcticient  in  quantity, 
or  almost  if  not  quite  suppressed.  This  partial  sup- 
pression may  last  for  an  indefinite  period,  during  which 
a  liuid  more  or  less  resembling  urine  is  discharged  from 
the  stomach.  In  some  cases  urea  has  been  detected 
in  the  vomited  matters;  but  statements  of  this  kind 
must  always  be  received  with  caution.  xV  much  more 
common  symptom  is  retention  of  urine,  due  either  to 
spasm  of  the  neck  of  the  bladder  or  to  paralysis  of  the 
detrusor  urina\  In  not  a  few  cases  the  retention  is  a 
purely  voluntary  act.  Irritation  of  the  bladder,  shown 
by  constant  desire  to  pass  water,  is  a  very  troublesome 
symptom  in  many  hysterical  patients.  If  the  habit  of 
frequent  micturition  be  indulged  in  the  bladder  soon 
becomes  intolerant  of  its  contents. 

Other  secretions  are  less  frequently  disordered  ;  but 
in  some  cases  the  liver  becomes  inactive,  and  the 
biliary  secretion  is  lessened.  Pale  stools,  constipation, 
and  symptoms  of  melancholia  are  the  ordinary   results. 


COURSE  OF  HYSTERIA.  m 


In  comparatively  rare  cases  the  breasts  become  swollen 
and  even  a  little  milk  is  secreted  during  the  attacks. 

One  of  the  most  extraordinary  facts  connected  with 
hysteria  is  that,  notwithstanding  the  many  and  various 
disorders, the  patient^s  general  health  often  remains  good, 
and  the  nutritive  functions  appear  to  be  properly  dis- 
charged, even  when  the  amount  of  food  taken  is  very 
small  indeed. 

Course^  Duration,  and  Results.  Hysteria  is  in  almost 
all  cases  a  chronic  affection,  and  unattended  by  any 
danger  to  life ;  once  developed,  some  of  its  manifesta- 
tions may  recur  at  intervals  during  the  life-time  of  the 
patient.  In  rare  instances,  after  a  few  acute  paroxysms, 
combated  by  suitable  measures,  the  disorder  comes  to 
an  end.  The  differences  in  its  course  depend  in  great 
degree  upon  the  psychical  condition  of  the  patient  and 
the  circumstances  and  influences  by  which  she  is  sur- 
rounded. In  the  early  stages  much  improvement  can 
generally  be  effected  by  judicious  treatment  persever- 
ingly  carried  out.  In  chronic  cases,  e.g.,  those  in 
which  the  symptoms  have  been  manifested  during 
twelve  months  or  more,  complete  recovery  is  decidedly 
uncommon.  ^Even  in  favourable  cases  the  morbid 
excitability  of  the  nervous  system  is  apt  to  betray  itself 


112  FMO  GNOSIS  OF  SYS  TIE  RI A . 

under  the  influence  of  very  slight  causes,  and  recurrence 
of  the  symptoms,  perhaps  at  very  long  intervals,  is  the 
ordinary  rule.  The  symptoms,  however,  generally 
become  milder  and  less  frequent  with  advancing  years. 
There  are  certain  forms  of  hysteria  which  merge 
gradually  into  moral  insanity,  or  monomania,  and  other 
varieties  of  mental  unsoundness.  With  regard  to  other 
results  of  the  complaint,  in  rare  instances  the  patients 
sink  into  a  low  anaemic  state  and  die  from  inanition 
and  exhaustion.  Death  has  also  occurred  from  suffo- 
cation during  the  paroxysm,  but  in  such  cases  some  of 
the  phenomena  of  epilepsy  are  generally  superadded  to 
those  of  hysteria. 

Prognosis.  Hysteria  very  rarely  involves  any  danger 
to  life,  though  it  often  causes  much  trouble  and  anxiety 
to  the  patient  and  her  friends.  When  the  symptoms 
begin  early,  and  do  not  subside  at  puberty  or  after 
marriage,  they  are  apt  to  last  for  life;  when  they  first 
show  themselves  during  the  third  decade  they  are  more 
likely  to  disappear  eventually.  When  dependent  on 
slight  lesions  of  the  genital  organs  the  symptoms 
usually  subside  after  the  cure  of  the  local  disorder. 
Weak  anaemic  subjects  presenting  symptoms  of 
hysteria  are    more   amenable   to    treatment    than   full 


DIAGNOSIS  OF  HYSTERIA.  113 

blooded,  vigorous  women.  Hysteria  may  terminate  (1) 
in  complete  and  permanent  recovery  ;  (2)  in  recovery 
fo;'  a  time,  to  be  followed  by  a  return  of  some  of  the 
symptoms ;  (3)  the  complaint  may  merge  into  de- 
cided insanity  or  the  patient  may  become  phthisical. 
In  the  absence  of  complications_,  death  is  a  very  rare 
termination.  A  few  hysterical  subjects  have  been 
allowed  to  starve  themselves  to  death^  and  others  have 
died  from  dyspnoea  during  a  paroxysm.  Such  instances 
are^  however,. quite  exceptional. 

Diagnosis.  Epilepsy  is  the  affection  W\Xh  which  the 
paroxysms  of  hysteria  are  most  liable  to  be  confounded, 
and  it  is  sometimes  a  little  difficult  hastily  to  determine 
the  real  nature  of  the  symptoms  in  a  given  case.  The 
distinction  is,  however,  of  extreme  importance  in  view 
of  the  gravity  of  epilepsy  and  the  often  trivial  character 
of  hysteria.  When  the  two  disorders  coexist  the 
symptoms  of  epilepsy  may  be  very  prominent,  but  the 
manner  in  which  the  attack  comes  on  and  subsides  is 
generally  sufficient  to  guide  the  diagnosis.  The  principal 
features  which  distinguish  the  hysterical  paroxysms 
from  those  of  epilepsy  are  as  follows  : — In  the  former, 
unless  as  the  result  of  shock,  the  paroxysm  is  not 
sudden,  but  comes  on  after  other  symptoms  have  shown 

8 


114  DIAGNOSIS  OF  HYSTERIA. 

themselves;    the    premonitory    cry  or    scream    is    less 
common  ;  when  the  patient  fal]s_,  a  chair  or  sofa  is  usually 
at  hand  to  receive  her ;  the  features  are  seldom  distorted, 
the  tongue  is  not  bitten  ;  the  pupils  react  to  the  influence 
of  light;  respiration  never  ceases,  and  the  face,  though 
red,   does   not  become  livid ;    laughing,    sobbing,    and 
perhaps  talking  go  on  continuously,   or  at  intervals ; 
and  throughout  the  paroxysm  there  are  evidences  of  a 
concealed  will,  and  in  not  a  few  cases  an  unmistakable 
degree  of  consciousness  ;  the  subsidence  of  the  paroxysm 
is  not  followed  by  coma.     In  epilepsy  the  attack  comes 
on  suddenly;  the  patient  usually  utters  a  loud  cry;  the 
features  are  much  distorted,  the  tongue  is  often  bitten; 
the  pupils  are  insensible  to  light ;  respiration  ceases  at 
intervals,  and  the  face  is  livid  and  turgid ;  the  convul- 
sions are  less   extensive,  but  injuries  often  result;  the 
patient  does  not   laugh,  cry,  or  talk,  but  is  absolutely 
unconscious  from  the  beginning,  and  a  comatose  state 
follows   the   paroxysm.      In    hysteria   the    convulsions 
may  be  extremely  violent,  and  may  go  on  for  hours,  but 
they  are  more  or  less  under  the  control  of  the  patient, 
and  can  often  be  arrested,  inasmuch  as  some  degree  of 
consciousness  is  preserved.     In  epilepsy  consciousness 
is  lost,  and  the  patient  has  no  control  over  the  convul- 


DIAGNOSIS  OF  HYSTERIA.  i  rg 

sive  movements,  which  are  generally  of  short  duration. 
The  differences  between  hystero-epilepsy  and  true 
epileptic  convulsions  have  been  already  mentioned  (see 
page  97). 

The  distinction  of  hysterical  hemianaesthesiafrom  loss 
of  sensation  due  to  cerebral  lesions  is  a  matter  of 
considerable  importance.  In  the  former  condition  an 
account  of  other  hysterical  symptoms  will  rarely  fail  to 
be  elicited  on  careful  inquiry,  and  the  hemianaesthesia  is 
never  permanent,  though  it  may  last  for  long  periods. 
Moreover,  the  symptoms  may  from  time  to  time  dis- 
appear and  then  recur.  Such  changes  are,  of  course, 
never  observed  in  organic  hemianaesthesia.  It  has 
been  stated  that  derangements  of  the  special  senses 
accompanying  hemianaesthesia  are  indicative  of  hys- 
teria. This,  however,  is  not  correct,  for  in  hemianaes- 
thesia, due  to  organic  causes,  similar  derangements  are 
occasionally  observed. 

Nerve-prostration  or  '^neurasthenia^'  more  or  less 
resembles  hysteria  in  some  of  its  features.  The  two 
disorders  may  coexist;  the  former,  indeed,  is  a  pre- 
disposing cause  of  the  latter,  but  either  may  be  present 
alone.  In  neurasthenia,  convulsions,  paroxysmal  attacks, 
the  globus    hystericus,    and  other  symptoms    of    local 


ii6  DIAGNOSIS  OF  HYSTERIA. 

spasm  are  absent;  there  is  never  any  decided  amount 
of  anaesthesia;  the  patients  generally  have  a  weak  and 
depressed  look,  and  their  condition  neither  fluctuates 
from  time  to  time  nor  improves  in  the  absence  of  proper 
remedial  measures.  In  hysteria^  on  the  other  hand,  the 
paroxysms  are  generally  prominent  symptoms;  anaes- 
thesia is  common ;  the  patients  frequently  appear  strong,, 
healthy,  and  full  of  energy  ;  the  condition  varies 
greatly,  and  often  changes  in  the  most  unexpected 
manner,  and  complete  recovery  may  take  place^  with 
or  without  treatment. 

The  effects  of  sub-acute  myelitis  of  the  anterior 
cornua  of  the  spinal  cord  more  or  less  resemble  the 
symptoms  of  hysterical  paraplegia.  The  chief  points 
of  distinction  are  as  follows  : — In  hysteria  the  patellar 
reflex  is  retained  and  sometimes  exaggerated;  the 
electro-muscular  contractility  is  either  normal  or  only 
slightly  diminished ;  the  reaction  of  degeneration  is 
never  observed  ;  there  is  no  interference  with  micturition 
and  defaecation;  the  temperature  of  the  limbs  is  not 
much  reduced,  and  bed-sores  are  not  liable  to  form. 
In  polio-myelitis  the  patellar  reflex  is  diminished  or  lost; 
the  reaction  of  degeneration  can  always  be  detected  > 
the  functions  of  the  bladder  and  rectum  are  interfered 


TREA  TMENT  OF  HYSTERIA.  1 1 7 

with  j  the  temperature  of  the  limbs  is  reduced  and  bed- 
sores are  common.  Other  differences  between  oro^anic 
paralyses  and  those  of  hysterical  origin  have  been  already 
referred  to  (see  page  98). 

Treatment.  Three  classes  of  remedial  measures  are 
required  in  the  treatment  of  hysteria  :  first,  those  which 
are  of  a  prophylactic  character ;  secondly,  those  which 
are  calculated  to  cure  the  disease ;  and,  thirdly,  those 
which  are  required  for  the  cure  or  relief  of  the  prominent 
symptoms. 

1.  In  all  cases  of  hysteria  minute  inquiry  should  be 
made  into  the  family  history  of  the  patient.  If,  as  is 
usually  the  case,  there  be  an  inherited  tendency  towards 
nervous  affections,  the  symptoms  mav  be  expected  to 
prove  much  more  obstinate  than  when  such  tendency 
is  absent.  When  hysterical  manifestations  appear  in  a 
young  girl  whose  mother  is,  or  has  been,  similarly 
affected,  there  can  be  no  doubt  as  to  the  plan  which 
ought  to  be  pursued.  The  child  should  be  removed 
from  its  home  and  placed  under  proper  care  and  treat- 
ment. Kind,  but  firm,  management ;  plain,  but  nutri- 
tious, diet;  plenty  of  exercise  in  the  open  air;  regular 
hours;  tepid  or  cold  baths;  attention  to  all  the  bodily 
functions,  and  mental  occupation  of  an  interesting  but 


ii8  tri:atment  of  hysteria. 

not  irksome  character,  will  afford  the  best  chance  of 
eradicating  the  seeds  of  the  nervous  disorder.  Excite- 
ment, whether  in  the  form  of  work  or  play^  should  be 
scrupulously  interdicted.  These  measures  act  by  im- 
proving the  general  state  of  nutrition  of  the  nervous 
system  and  lessening  its  excitability,  and  they  are 
applicable  to  all  cases  of  hysteria  in  young  subjects. 

2.  The  measures  calculated  to  cure  the  disease  re- 
quire to  be  considered  at  some  length.  In  the  first 
place,  every  endeavour  should  be  made  to  ascertain  the 
cause,  and  to  deal  with  it  as  completely  as  possible.  If 
there  be  symptoms  of  uterine  disorder  a  proper  examina- 
tion should  be  made  and  the  necessary  treatment 
adopted  for  the  cure  of  any  lesion  or  displacement  that 
may  be  detected.  Great  caution  is,  however,  necessary 
with  regard  to  an  examination  in  all  these  cases ;  it 
should  never  be  undertaken  unless  there  are  the 
strongest  reasons  for  anticipating  that  benefit  will 
result.  On  the  other  hand,  it  is  bad  practice  to  allow 
an  hysterical  patient  to  suffer  continuously  from  symp- 
toms of  a  displaced  uterus  without  suggesting  an 
examination.  It  is  useless  to  prescribe  tonics,  anti- 
spasmodics, and  the  like,  while  the  local  cause  of  the 
disorder  remains  in  full  operation. 


TREA  TMENT  OF  SYSTERIA .  119 

The  general  condition  of  the  patient  is  the  next  point 
for  consideration.  Hysteria  is  not  connected  with  any 
one  state  of  the  general  health  j  some  hysterical  patients 
are  weak  and  anaemic_,  others  are  robust  and  plethoric. 
For  the  former^  rest^  tonic  treatment  and  regimen  are  of 
course  indicated ;  the  latter  will  be  benefited  by  purga- 
tives, a  reduced  diet,  and  plenty  of  exercise.  Saline 
purgatives,,  e.g.,  sodium  or  magnesium  sulphate,  are 
generally  suitable  for  these  patients,  and  the  salts  may 
be  conveniently  given  in  the  form  of  the  Carlsbad 
waters.  The  springs  of  Marienbad  and  of  Kissingen 
are  also  serviceable. 

The  treatment  of  the  mental  condition  of  the  patient 
is  of  the  highest  importance,  but  much  difficulty  is  often 
encountered  in  this  particular.  The  physician  should 
endeavour  to  gain  the  confidence  of  his  patient;  he 
should  assure  her  that  he  quite  understands  her  ail- 
ment, and  that  her  recovery  is  certain  if  his  directions 
are  properly  attended  to.  Notwithstanding  the  ex- 
aggeration which  is  so  prominent  a  feature  of  this  com- 
plaint, it  must  always  be  borne  in  mind  that  much  of 
the  suffering  is  real,  and  not  imaginary.  It  seldom 
answers  to  treat  the  patient  harshly ;  to  tell  her  that 
her  ailments  are  non-existent  and  that  she  is  shamming 


I20  TMI:ATMENT  OF  HYSTERIA. 

is  almost  certain  to  make  her  worse ;  she  broods  over 
and  exaggerates  her  troubles^  and  probably  develops  new 
symptoms.  On  the  other  hand^  nothing  can  be  more 
mischievous  for  the  patient  than  to  treat  her  as  though 
she  were  as  ill  as  she  believes  herself  to  be;  the  adop- 
tion of  this  course  by  well-intentioned  but  misguided 
friends  and  relatives  may  constitute  a  serious  obstacle  to 
the  efforts  of  the  physician.  Hence  it  is  that  in  many 
cases  the  most  effectual  plan  of  cure  is  to  change  the 
circumstances  under  which  the  patient  is  placed,  and  to 
bring  a  fresh  set  of  influences  to  bear  upon  her.  Such 
a  plan  is  not  always  feasible,  and  in  mild  cases  it  can 
scarcely  be  regarded  as  necessary.  For  these  latter, 
after  due  inquiry  has  been  made  into  all  the  circum- 
stances which  may  have  contributed  towards  the  develop- 
ment of  the  symptoms,  the  measures  described  on  page 
117  should  be  sedulously  adopted.  What  the  patient 
should  do  and  what  she  must  not  do  should  be  very 
clearly  specified.  All  causes  of  emotional  excitement, 
and  especially  the  reading  of  sensational  literature,  so 
mischievous  to  many  girls,  must  be  absolutely  shunned. 
Equal  care  should  be  taken  in  the  selection  of  amuse- 
ments and  occupation_,  the  great  object  being  to  divert 
or  repress  emotional  excitement,  to  induce  the  patient 


TREATMENT  OF  HYSTERIA.  121 

to  interest  herself  in  rational  and  useful  tasks,  and  to 
strengthen  the  power  of  the  mind  and  the  control  of 
the  will.  Having  thus  attended  to  the  mental  features 
•of  the  disorder^  the  hygienic  remedies  may  be  applied 
with  every  prospect  of  success. 

With  regard  to  drugs_,  tonics,  anti-spasmodics,  seda- 
tives, and  stimulants  may  be  required  as  adjuvants,  or  as 
special  remedies  in  certain  cases.  Among  tonics, 
quinine,  iron,  the  salts  of  zinc  and  of  copper  may  be 
given  with  the  view  of  lessening  the  irritability  of  the 
nervous  system.  Among  anti-spasmodics  must  be 
mentioned  the  old  remedies,  asafoetida  and  valerian, 
aromatic  spirit  of  ammonia  and  camphor.  These  are 
sometimes  useful  in  the  treatment  of  the  milder  symp- 
toms. Something  has  to  be  given,  if  only  to  relieve  the 
anxiety  of  the  patient  and  her  friends ;  and  medicines 
which  appeal  strongly  to  the  nerves  of  taste  and  smell 
serve  to  occupy  her  attention  and  to  divert  it  from 
herself.  Sedatives,  anodynes,  and  narcotics  are  often 
necessary  in  dealing  with  hysteria;  but  their  use  requires 
great  caution.  The  bromides  are  the  best  remedies  of 
the  sedative  class;  they  are  especially  indicated  for 
cases  in  which  the  symptoms  of  motor  disorder  are  very 
prominent.     Anodynes  are  often  required  for  the  relief 


122  TEJEATMENT  OF  HYSTERIA. 

of  pain,  and  narcotics  to  produce  sleep ;  for  the  former 
purpose  opium  and  its  various  preparations^  henbane, 
and  cannabis  indicaare  the  best  remedies  ;  for  the  latter 
the  bromides,  chloral,  butyl  chloral,  and  opium  are  at  the 
disposal  of  the  physician.  As  a  general  rule  opium 
should  be  avoided  in  hysterical  cases.  It  must  always 
be  borne  in  mind  that  the  symptoms  for  which  it  is 
adapted  are  liable  to  frequent  recurrences  which  would 
necessitate  increased  doses.  Moreover,  in  many  hys- 
terical subjects  opium  is  apt  to  produce  an  effect  quite 
opposite  to  that  which  is  desired  ;  instead  of  calming^ 
the  patient  it  often  causes  great  excitement.  It  may, 
however,  be  absolutely  necessary,  e.g.,  for  the  relief  of 
severe  neuralgic  pain.  Under  such  circumstances  the 
subcutaneous  injection  of  morphia  will  probably  be  the 
best  method  of  employing  the  drug;  but  the  applica- 
tion of  the  remedy  must  never  be  entrusted  to  the  patient 
or  her  friends. 

3.  For  the  relief  of  prominent  symptoms  remedies 
and  measures  of  the  most  varied  kind  are  liable  to  be 
required.  During  a  convulsive  paroxysm  the  patient 
should  be  placed  in  a  recumbent  position,  with  her  dress 
loosened,  especially  about  the  neck  ;  if  necessary,  enough 
restraint  should  be  employed  to  prevent  her  from  injur- 


TREATMENT  OF  SYSTERIA.  12.^ 

ing  herself.  To  rouse  the  patient,,  and  to  make  her 
exercise  such  power  of  self-control  as  she  possesses, 
cold  water  may  be  dashed  over  the  face  and  neck,  and 
further  treatment  of  this  kind  should  be  promised  when- 
ever exaggeration  is  manifest.  To  fulfil  a  similar  pur- 
pose it  is  often  sufficient  to  apply  irritant  substances  to 
the  nostrils  ;  the  vapour  of  burnt  feathers  is  an  old 
remedy  of  this  class,  but  smelling-salts  are  equally 
efficacious  and  more  convenient.  If  the  patient  can 
swallow^,  a  little  ether,  ammonia,  and  asafoetida  may  be 
administered;  but,  as  a  general  rule,  it  is  better  not  to 
give  medicines  by  the  mouth  until  the  movements  have 
finally  subsided.  Difficulty  of  swallowing,  with  irrita- 
.tion  of  the  throat  and  larynx,  is  likely  to  be  set  up  and 
to  aggravate  the  paroxysm.  In  adult  patients,  when, 
as  sometimes  happens,  the  convulsions  subside  and 
recur  at  short  intervals,  and  the  condition  threatens  to 
be  indefinitely  protracted,  the  administration  of  a 
turpentine  enema  will  generally  be  found  the  best 
means  of  arresting  the  symptoms.  Another  method, 
which  has  lately  been  recommended  for  the  same  pur- 
pose, is  that  of  making  firm  and  sustained  pressure  by 
applying  the  hands  over  one  or  both  ovaries.  In  some 
cases  the  convulsions  immediately  cease  when  pressure 


124  TREATMENT  OF  HYSTERIA. 

is  applied^  but  the  effect  may  be  only  transient.  Inhala- 
tions of  chloroform  or  ether  may  be  cautiously  tried 
when  the  convulsions  are  very  severe.  It  is  not  necessary 
to  induce  complete  insensibility;  as  the  convulsions 
become  less  violent,  the  patient  will  probably  fall  into  a 
quiet,  sleepy  state  of  some  hours'  duration. 

In  addition  to  the  free  use  of  cold  water  to  the  head 
and  neck  it  is  sometimes  advisable  to  adopt  other 
measures  likelv  to  produce  a  decided  effect  on  the 
patient^s  mind.  Thus  the  physician  may  assert  in  a  very 
emphatic  manner  that  unless  the  symptoms  cease  at 
once,  or  that  if  they  recur,  it  will  be  necessary  to  shave 
•the  head  and  apply  a  blister,  or  to  adopt  some  other 
disagreeable  measures.  Even  when  the  patient  appears 
to  be  insensible  a  remark  of  this  kind  will  often  be 
appreciated  and  produce  a  good  effect.  When  scissors 
are  asked  for,  for  cutting  the  hair^  as  a  preliminary  to 
the  shaving  process,  an  improvement  will  generally  be 
noticed.  If  in  a  very  severe  case  these  or  similar 
measures  prove  successful  it  must  not  be  hastily 
assumed  that  all  the  symptoms  have  been  counterfeited. 
The  presentation  of  a  powerful  motive  for  restraining 
the  paroxysms  and  the  sedative  influence  of  fear  are 
sufficient  to  counterbalance  the  reflex  excitability  of  the 


TREATMENT  OF  HYSTERIA.  125 

automatic  centres,  and  the  forc£  of  the  will,  previously 
in  abeyance,  is  set  free  to  act  in  the  necessary  direc- 
tion. 

The  treatment  of  the  other  prominent  symptoms  of 
hysteria  does  not  require  a  very  lengthy  description. 
The  derangements  of  the  stomach  and  intestines,  the 
palpitation,  cough,  urinary  disorders,  etc.,  must  be 
treated  on  general  principles,  due  attention  being  paid 
to  the  condition  underlying  the  various  manifestations. 
The  hyperaesthesia,  which  is  often  so  great  a  trouble,  is 
best  treated  by  full  doses  of  the  bromides,  massage,  and 
the  application  of  the  galvanic  current;  for  anaesthesia, 
faradism  and  the  metallo-therapeutic  treatment  is  likely 
to  yield  the  best  results. 

The  treatment  of  hysterical  anaesthesia  and  other 
syixptoms  by  the  application  of  metals  to  the  surface 
of  the  body  has  attracted  considerable  attention  of  late. 
The  method  was  known  and  practised  in  early  times, 
and  has  recently  been  experimented  upon  by  Charcot, 
who  was  led  to  investigate  the  subject  by  the  reputed 
successes  of  a  certain  Dr.  Burg,  in  Paris.  In  dealing 
with  a  case  of  anaesthesia,  various  metals  have  to  be 
tried  in  order  to  discover  the  particular  one  to  which 
the  patient  is  sensitive.     A   piece  of  the  metal  in  the 


126  TREATMIENT  OF  HYSTERIA. 

form  of  a  disk  is  then  applied  to  the  skin  of  the 
anaesthetic  part,  and  kept  in  position  for  about  twenty 
minutes.  If  the  plan  succeeds  it  will  be  found  that 
the  normal  sensibility  is  restored  in  the  immediate 
neighbourhood  of  the  disk^  and  that  the  improvement 
gradually  spreads  until  restoration  is  complete.  In  a 
similar  manner  it  is  alleged  that  colour-blindness  and 
other  disorders  of  special  senses  may  be  cured  by  apply- 
ing the  disks  to  the  skin  in  the  neighbourhood  of  the 
affected  part.  Disks  of  gold  are  said  to  be  efficacious 
in  the  largest  number  of  cases ;  but  in  some  more 
benefit  results  from  the  use  of  silver^  zinc,  or  copper. 
In  order  to  strengthen  the  action  of  the  metal  it  is  re- 
commended that  one  of  its  soluble  salts  should  be  given 
internally  for  a  shorter  or  longer  period.  Thus,  if  the 
patient  prove  sensitive  to  gold  the  chloride  of  that 
metal  and  sodium  is  administered  daily,  and  the  same 
plan  is  adopted  with  silver,  zinc,  copper,  etc.  It  is  not 
a  little  curious  that  similar  effects  have  been  produced 
by  the  application  of  disks  of  wood  and  other  non- 
metallic  substances.  It  is  impossible  to  do  more  than 
speculate  as  to  the  manner  in  which  the  effects  are  pro- 
duced. Some  assert  that  the  metals  themselves  exercise 
a  specific  influence,   or  that  they  generate  electric  cur- 


tri:atment  of  hysteria.  127 


rents,  but  this  theory  is  scarcely  tenable  in  view  of  the 
similar  effects  alleged  to  have  been  produced  by  non- 
metallic  substances.  It  is  more  probable  that  such 
applications  produce  their  effect  by  directing  the  atten- 
tion of  the  sufferer  to  the  affected  part,  and  by  keeping: 
alive  and  stimulating  the  expectation  of  the  cure.  In 
hysterical  patients  it  is  scarcely  possible  to  assign  any 
•limit  to  the  influence  of  "  expectant  attention."" 
Another  remarkable  phenomenon  has  been  reported  as 
resulting  in  some  cases  from  the  application  of  the 
metals ;  the  hemianaesthesia  has  disappeared  from  the 
affected  side  and  transferred  itself  to  the  other  half  of 
the  body  which  was  previously  normal. 

For  paralyses  of  hysterical  origin  galvanism  and 
faradism  are  the  chief  remedies;  the  latter  is  especially 
indicated  whenever  there  are  any  signs  of  muscular 
atrophy.  These  forms  of  paralysis  are  apt  to  prove 
very  obstinate,  but  unless  connected  with  some  oro"anic 
■cause  the  symptoms  in  not  a  few  cases  disappear 
suddenly  and  spontaneously.  It  is  in  many  of  these 
cases  that  the  Weir  Mitchell  system  of  treatment  acts 
satisfactorily.  Full  particulars  with  reference  to  this 
plan  of  treating  the  worst  forms  of  hysteria  will  be 
found  in  the  chapter  on  Neurasthenia.     In  its  principal 


1 28  TREA  T3IENT  OF  SYS  TERIA . 

details  it  may  be  described  as  consisting  of  seclusion^ 
rest,  high  feeding,  massage,  and  electricity.  It  yields, 
according  to  Dr.  Playfair,*  the  most  satisfactory  results 
in  the  thoroughly  broken-down  and  bedridden  cases. 
"  It  is  my  experience  that  the  worse  the  case  is  the 
more  easy  and  certain  is  the  cure,  and  the  only  dis- 
appointments I  have  had  have  been  in  dubious,  half 
and  half  cases."  It  would  seem  that  for  hysterical 
patients  whose  appearance  is  that  of  good  health  some 
hydropathic  form  of  treatment  is  more  suitable.  If  the 
patient  can  be  induced  to  take  them,  cold  shower-baths 
sometimes  produce  an  excellent  tonic  effect ;  moreover, 
the  "  bracing  up  of  the  mind  to  the  shock  of  the  cold 
shower-bath  is  a  capital  exercise  for  the  W'Cak-willed 
power  of  the  hysterical  patient.^^  To  obtain  the  full 
benefit  of  hydropathic  treatment  it  is  often  desirable  to 
remove  the  patient  from  her  home  and  place  her  in  an 
institution  where  the  necessary  appliances  are  available. 
The  discipline,  the  diet,  and  the  close  personal  super- 
vision are  all  helpful  adjuncts  to  the  cure. 


*  "  The  Systematic  Treatment  of  Nerve   Prostration  and  Hysteria,' 
P-S- 


CHAPTER    V. 

EPILEPSY. 


Epilepsy,  Definition  and  Forms  of — Historical  Notices  and 
Geographical  Distribution  of  the  Disorder — Causes — In- 
fluence of  Hereditary  Predisposition — Date  of  First 
Attacks— Drunkenness  -  Sexual  Excesses — Lesions  of  the 
Nervous  System — Dr.  Brown-Sequard's  Experiments — Reflex 
Epilepsy — Ocular  Defects  as  a  Cause  of  Epilepsy — Dr. 
Stevens'  Views — Exciting  Causes — Epilepsy  and  Gout — 
Morbid  Anatomy  and  Pathology — No  Sp'icial  Lesion — Seat 
OF  the  Disorder — The  Epileptic  Change — Dr.  Hughlings- 
Jackson's  Views — Dr.  Brown-Sequard's  Views — Symptoms  of 
the  Paroxysm — The  Phenomena  in  Detail — The  Milder 
Forms  of  Epilepsy— Irregular  Forms  —  The  Epileptoid 
States — Reflex  Epilepsy — Jacksonian  Epilepsy — The  Course 
OF  the  Disorder — Mental  Symptoms — Diagnosis — Epilepsy 
Distinguished  from  Apoplexy,  Syncope,  Hysteria,  and  In- 
fantile Convulsions — Prognosis — Treatment — During  the 
Intervals— Hygienic  Measures — Medicines — The  Bromides, 
Atropine,  Zinc,  Silver,  Vegetable  Tonics;  and  Anti- 
spasmodics— Empirical  Remedies — Electricity — H  yd  rot  her  a- 
PEUTics — Treatment  During  the  Paroxy'sm. 


Epilepsy  is  a  chronic  nervous  affection,  without  known 
anatomical  basis_,  and  characterized  by  attacks  of  loss 
of  consciousness,  which  in  typical  cases  are  associated 
with  general  or  partial   convulsions   of  a  more  or  less 

9 


I30  FORMS  OF  FPILFPSY. 

violent  character.  This  combination  of  phenomena  is 
regarded  as  constituting  '^  true  epilepsy/'  the  haiit  mal 
of  the  French  writers ;  but  there  are  many  other 
anomalous  and  milder  forms  of  the  disorder  in  which 
motor  symptoms  are  absent.  These  constitute  the 
petit  mal  of  the  French,  the  "  abortive  epilepsy  "  of 
English  writers.  The  term  ^'  epileptoid  "  is  applied  to 
conditions  of  a  still  more  anomalous  character,  and 
observed  in  persons  of  a  distinctly  epileptic  tendency. 
Such  symptoms  as  migraine,  vertigo,  syncope,  halluci- 
nations, and  other  indications  of  nervous  disorder  oc- 
curring periodically  and  paroxysmally  in  persons  of  this 
description  have  been  thus  classified. 

Epilepsy  has  been  known  from  very  early  times.  Dr. 
Hirsch  says:  "Of  all  the  diseases  included  in  the  group 
•  of  neuroses  none  shows  a  prevalence  so  general  in  time 
and  place  as  epilepsy ;  none  is  so  constant  a  presence 
in  the  morbid  life  of  humanity  ;  none  has  so  markedly 
the  ubiquitous  character."  The  affection  is  very 
common  even  in  Arctic  latitudes ;  in  central  and 
southern  Europe  its  average  frequency  is  said  to  be 
about  I  or  1*5  per  1,000.  Its  geographical  distribution 
and  relative  frequency  are  uninfluenced  by  conditions  of 
climate  and  soil.     According  to   the  authority  already 


CA  USJES  OF  U  PILE  PS  F.  1 3  r 

quoted,  epilepsy  is  as  frequent  in  tropical  and  sub- 
tropical countries  as  in  cold  and  temperate  latitudes. 
^'  Peculiarities  of  race  and  nation  have  no  influence 
whatsoever  on  the  occurrence  of  epilepsy  ;  "  the  same 
types  of  the  disorder  are  to  be  found  everywhere;  the 
natives  of  New  Zealand  are  the  only  race  for  whom 
immunity  has  ever  been  claimed. 

The  causes  of  epilepsy  are  of  a  very  indefinite  char- 
acter, and  their  respective  values  cannot  be  accurately 
estimated.  As  a  predisposing  cause  heredity  is  the 
most  important.  It  is  often  noticed  that  among  the 
children  of  an  epileptic  parent  one  or  more  exhibit 
symptoms  of  the  disease.  In  another  set  of  cases  a 
history  of  some  other  nervous  disorder  is  all  that  can 
be  ascertained^  and  in  both  classes  it  sometimes 
happens  that  the  immediate  progeny  escape  and  that 
their  descendants  suffer.  Habitual  drunkenness  in  the 
parents  is  a  predisposing  cause  of  epilepsy  in  their 
descendants;  it  has  also  been  stated  that  children  be- 
gotten by  a  father  in  a  state  of  intoxication  are  very 
liable  to  become  epileptic.  Besides  nervous  disorder, 
other  morbid  conditions  in  the  parents  contribute 
towards  the  production  of  epilepsy  in  the  offspring.  Of 
these   the  most  important  are  :  exhaustion    from    ex- 


CAUSES  OF  EPILEPSY. 


cesses,  sexual  or  otherwise ;  nearasthenia  resulting 
from  excessive  mental  labour ;  a  low  state  of  system 
from  want  of  proper  nourishment  ;  anaemia,  rickets, 
and  scrofula.  Epilepsy  is  not  unfrequent  in  women 
hereditarily  predisposed  to  gout. 

.  When  the  hereditary  predisposition  exists  the  dis- 
order generally  manifests  itself  before  the  twentieth 
year.  In  such  cases  it  is  often  noticed  that  the 
patients  have  suffered  from  convulsions  in  early  life. 
First  attacks  are  most  frequent  during  the  period  of 
puberty ;  seventy-five  per  cent,  of  all  cases  occur  in 
persons  under  twenty  years  of  age.  When  epilepsy 
appears  for  the  first  time  after  that  age  has  been 
reached  the  disorder  is  not  to  be  attributed  to  here- 
ditary predisposition  alone.  In  liability  to  suffer  there 
is  little,  if  any  difference  between  the  sexes.  With 
regard  to  other  causes,  epilepsy  may  doubtless  be 
acquired ;  certain  influences  appear  to  be  capable  of 
inducing  the  epileptic  change  or  condition  in  the 
nervous  system,  while  other  influences,  of  a  more  de- 
finite character,  are  capable  of  provoking  an  attack. 

Drunkenness  plays  a  decided  part  in  the  production 
of  epilepsy,  and  some  intoxicating  agents  appear  to  be 
more  powerful  than  others  in  this   respect.     In   France 


CAUSES  OF  BPILJEFSY.  133 

epileptic  attacks  are  often  traceable  to  the  use  of 
absinthe ;  symptoms  closely  resembling  those  observed 
in  man  have  been  produced  in  dogs  by  the  continued 
administration  of  this  fluid.  Sexual  excesses  and  mas- 
turbation are  supposed  to  explain  the  occurrence  of 
epilepsy  in  a  somewhat  numerous  class  of  cases.  It  is, 
however,  probable  that  the  influence  of  these  causes  has 
been  over-estimated.  If  it  were  as  great  as  some 
authorities  have  imagined,  epilepsy  would  be  a  much 
more  common  disorder  than  it  really  is.  Many 
epileptics  practise  masturbation ;  but  the  vice  may  be 
regarded  as  the  consequence  rather  than  the  cause  of 
the  disorder.  Syphilis  is^  beyond  doubt,  an  occasional 
cause  of  epilepsy,  and  should  always  be  suspected  when 
in  a  male  subject  the  first  attack  occurs  after  the 
twentieth  year. 

In  some  cases  of  epilepsy  a  causal  connection  can 
be  shown  to  exist  between  certain  lesions  affecting 
various  parts  of  the  nervous  system  and  the  develop- 
ment of  the  epileptic  change.  Such  cases  are  especially 
interesting  from  the  light  they  throw  upon  the  patho- 
geny of  the  disease.  The  symptoms  are,  moreover^ 
closely  analogous  to  those  which  can  be  artificially 
produced    in    animals.      About    thirty    years    ago   Dr. 


134  CAUSES  OF  EPILEPSY. 

Brown-Sequard  showed  that  epileptic  attacks  could  be 
induced  in  guinea-pigs  by  injuring  certain  portions  of 
the  nervous  system — the  spinal  cord^  the  medulla 
oblongata^  the  cerebral  peduncles,  and  the  corpora  quad- 
rigemina — and  even  by  section  of  one  or  both  sciatic 
nerves.  In  from  four  to  six  weeks  after  the  injury 
epileptic  attacks  occurred  either  spontaneously  or  as  a 
result  of  irritating  the  cheek  and  the  antero-lateral 
region  of  the  neck_,  supplied  by  the  fifth  and  the 
occipital  nerves.  This  so-called  " epileptogenous  zone" 
is  on  the  same  side  as  the  injury,  except  when  the 
cerebral  peduncle  is  affected  ;  it  is  then  on  the  opposite 
side.  The  epileptic  state  can  also  be  produced  in 
guinea-pigs  by  giving  them  a  succession  of  slight  blows 
on  the  head.  General  convulsions  are  caused^  but  soon 
subside,  and  the  animal  appears  to  be  in  a  normal 
condition.  In  about  six  weeks  it  is  found  that  irritation 
of  the  face  and  neck,  as  before  mentioned,  induces  an 
attack  of  epilepsy.  It  is  worthy  of  note  that  the 
progeny  of  such  guinea-pigs  often  suffer  from  epileptic 
convulsions,  and  that  when  both  parents  have  been  ex- 
perimented upon,  few,  if  any,  of  the  offspring  escape. 
In  other  experiments  epileptic  convulsions  were  pro- 
duced by  removing  the  cortical  centre  for  the  anterior 


CAUSES  OF  EFILEPSY 


135 


extremity,  and  also  by  applying  a  strong  faradic  current 
to  the  cerebral  cortex  on  one  side. 

These  experiments  serve  to  explain  the  causation  of 
epilepsy  in  those  cases  in  which  the  disorder  is  con- 
sequent upon  lesions  of  nerves  and  nerve-centres.  In 
the  case  of  injury  to  peripheral  nerves  the  local  irrita- 
tion induces  by  degrees  central  changes  which  con- 
stitute the  epileptic  state.  Many  cases  are  on  record  in 
which  permanent  irritation  to  a  nerve,  caused  by  the 
presence  of  some  foreign  body,  e.g.,  a  fragment  of  glass, 
has  induced  convulsive  attacks,  which  ceased  after  the 
removal  of  the  offending  substance.  In  like  manner 
the  irritation  has  been  known  to  spread  from  cicatrices 
in  which  small  branches  of  nerves  were  included.  The 
cessation  of  the  symptoms  after  removal  of  the  cicatrix 
was  sufficiently  indicative  of  their  origin.  The  term 
"^  reflex  epilepsy  "  is  applicable  to  all  these  cases  and 
likewise  to  those  in  which  irritation  is  presumed  to 
spread  from  disease  situated  in  various  parts  of  the 
body.  Injury  of  the  brain  from  external  violence  has 
been  known  to  give  rise  to  symptoms  of  epilepsy.  It 
is  probable  that  in  young  subjects  the  complaint  is 
sometimes  attributable  to  overlooked  or  forgotten  causes 
of  this  character. 


136  CAUSES  OF  i:piljefsy. 

When,  however^  due  allowance  has  been  made  for 
the  influence  of  heredity,  injuries  and  other  causes, 
there  still  remain  manv  cases  whose  origin  cannot  be 
discovered. 

The  artificial  production  of  epileptic  symptoms  by 
rapidly  depriving  the  brain  of  arterial  blood  would  seem 
to  indicate  that  a  condition  of  cerebral  anaemia  is  at 
least  one  requisite  for  the  development  of  the  complaint. 
It  is  found  that  when  the  supply  of  blood  to  the  brain 
is  cut  off  or  reduced  to  a  minimum  coma  and  general 
epileptic  convulsions  are  produced,  and  that  these 
symptoms  cease  when  the  blood-supply  is  re-established. 
The  phenomena  are  probably  due  to  some  change  in  the 
nutrition  of  the  cells.  They  are  not  the  result  of 
diminished  pressure,  inasmuch  as  removal  of  the 
cerebro-spinal  fluid  does  not  cause  convulsions.  It 
has  further  been  proved  by  experiment  that  irrita- 
tion of  certain  peripheral  sensory  nerves  produces 
reflex  contraction  of  the  cerebral  arteries,  anaemia, 
and  epileptic  convulsions.  Dr.  Stevens,  of  New  York, 
asserts  that  certain  ocular  defects  play  a  considerable 
part  in  the  production  of  an  epileptic  tendency  in  young 
subjects.  He  reports  that  an  examination  of  ocular 
conditions  in   144  cases   of  epilepsy  demonstrated  the 


CA  USE  S  OF  E  PILE  PS  T.  ,  3  7 

existence  of  refractive  anomalies  in  a  far  greater  pro- 
portion than  that  which  exists  among  children  in 
general.  Insufficiency  of  the  motor  muscles  of  the 
eyes  was  also  discovered.  The  results  of  treatment 
served  to  confirm  the  supposition  that  epileptic  in- 
fluences might  arise  from  ocular'  defects.  Of  twenty- 
nine  cases  treated  by  supplying  proper  glasses  all  but 
two  were  either  cured  or  considerably  improved. 

A  reference  to  the  exciting  causes  of  epileptic  attacks 
will  conclude  this  part  of  the  subject.  In  some  patients 
the  attacks  are  apparently  spontaneous  ;  in  others  they 
result  from  mental  excitement  of  various  kinds.  The 
first  attack  is  sometimes  induced  by  fright^  and  the 
same  cause  often  induces  paroxysms  in  persons  subject 
to  the  complaint.  Sexual  causes  have  some  influence 
in  producing  an  attack;  thus  in  women  the  occurrence 
of  the  complaint  has  often  been  observed  to  coincide 
with  the  menstrual  periods^  and  with  pregnancy.  In 
both  sexes  attacks  have  been  known  to  occur  during 
sexual  intercourse.  Disorders  of  the  stomach_,  intes- 
tinal worms^  diseases  of  the  ear^  and  irritation  from 
disease  of  various  parts  of  the  body  are  sufficient  to 
excite  paroxysms  when  once  the  epileptic  change  has 
become    established.      In    another    class   of   cases   the 


138  PATHOLOGY  OF  EPILJEPS Y. 

attacks  supervene  upon  such  affections  as  scarlet  fever, 
measles,  whooping  cough,  small-pox,  and  diphtheria. 
In  some  patients  epilepsy  would  appear  to  be  connected 
with  gout,  the  convulsive  attacks  either  ceasing  or 
becoming  much  milder  after  the  development  of  acute 
symptoms  in  the  toe.  It  has  been  already  stated  that 
epilepsy  is  not  unfrequent  in  women  hereditarily  pre- 
disposed to  gout.  In  these  cases  the  attacks  are  doubt- 
less excited  by  the  accumulation  of  sodium  urate  in  the 
blood,  and  the  consequent  irritation  and  spasm  of  the 
cerebral  vessels.  It  has  been  alleged  that  epileptic 
seizures  have  sometimes  occurred  from  imitation, 
children,  and  girls  especially,  having  been  attacked  by 
the  complaint  while  merely  witnessing  the  convulsive 
paroxysms  in  others.  Such  a  result  might  follow  in  a 
person  hereditarily  predisposed  to  the  complaint,  but  in 
the  absence  of  such  tendency  such  a  causation  of  true 
epilepsy  is  at  least  very  improbable. 

Morbid  anatomy  and  pathology.  The  most  carefully - 
conducted  post-mortem  examinations  have  revealed 
nothing  that  can  explain  the  pathology  of  epilepsy ; 
they  only  show  that  the  disorder  does  not  depend  upon 
any  special  lesion  of  the  brain.  In  some  cases  no 
change   whatever   has   been    discovered ;  in  others   the 


PA  TROL  OGY  OF  i:  FILE  PS  Y.  1 39 

autopsy  has  revealed  thickening  and  induration  of  the 
bones  of  the  skull,  opacity _,  thickening,  and  adhesions  of 
the  cerebral  membranes^  effusions  into  the  ventricles^ 
induration  of  the  grey  and  vi^hite  substance.  All  these 
may  be  regarded  as  consequences  of  the  oft-recurring 
hyperaemia  during  the  convulsive  attacks.  Various 
alterations  in  the  shape  of  the  skull  have  been  noticed 
in  a  few  cases,  and  regarded  of  aetiological  importance. 
Of  these  perhaps  the  most  interesting  is  defective 
symmetry  of  the  cramum_,  as  a  result  of  imperfect 
development  of  one-half  of  it.  This  condition  has 
been  observed  in  persons  subject  to  epilepsy  from  early 
childhood.  In  the  majority  the  defect  has  been  found 
on  the  left  side,  and  it  is  interesting  to  notice  that  in 
these  patients  there  were  evidences  of  general  want  of 
development  of  the  right  side  of  the  body,  and  that  the 
convulsions  commenced  and  were  most  violent  on  that 
side.  The  capillary  dilatation  in  the  medulla  oblongata 
detected  in  some  cases  of  epilepsy  cannot  be  regarded 
as  having  any  definite  relation  to  the  disorder.  It  has 
been  noticed  in  non-epileptic  cases_,  and  is  probably  a 
secondary  result,  and  due  to  the  attacks  of  congestion. 

Until  within  the  last  few  years  the  pons  Varolii  and 
the  medulla  oblongata  were  looked  upon  as  the  parts 


I40  FATHOLOaY  OF  EPILEPSY. 

especially  implicated  in  the  production  of  epilepsy ;  but 
according  to  the  view  most  in  favour  at  the  present  day 
the  seat  of  the  disorder  is  to  be  found  in  the  corte^x 
cerebri.  The  principal  facts  adduced  in  support  of  the 
first-mentioned  view  are  as  follows  : — The  pons  Varolii 
contains  the  spasm-centre,  a  mass  of  ganglion  cells, 
reflex  irritation  of  which  causes  contraction  of  all  the 
muscles  of  the  body,  even  of  those  which  are  supplied  by 
cerebral  nerves.  The  medulla  oblongata  contains  the 
chief  vaso-motor  centre,  irritation  of  which  causes  con- 
traction of  the  muscular  coat  of  the  arteries,  especially 
of  those  of  the  brain.  The  characteristic  symptoms  of 
the  epileptic  attack,  the  loss  of  consciousness  and  con- 
vulsions, can  be  evoked  by  irritation  of  these  centres. 
The  former  symptom  results  from  the  anaemic  state  of 
the  brain  suddenly  produced  by  the  constriction  of  the 
vessels.  The  abortive  attacks,  in  which  there  is  loss  of 
consciousness  without  convulsions,  are  explained  by 
supposing  that  only  the  vaso-motor  centre  is  irritated ; 
and  when  convulsions  occur  without  loss  of  conscious- 
ness the  spasm-centre  alone  is  supposed  to  be  affected. 
In  order  to  explain  the  condition  of  the  brain  in 
epilepsy  it  is  assumed  that  some  portions  of  it,  notably 
the  pons  Varolii   and   the  medulla  oblongata,  are  in  a 


PA  THOL  0  a  Y  OF  JEPILEPS  Y.  141 

State  of  abnormally  increased  irritability — the  so-called 
"  epileptic  change."  I'he  attack  results  when  the 
activity  of  the  nerve-centres  situated  in  these  parts  is 
called  into  play  by  appropriate  stimuli.  It  is  doubtful 
whether  both  centres  are  acted  upon  at  once  or  whether 
the  vaso-motor  centre  is  first  irritated^  the  spasm-centre 
being  secondarily  affected  by  the  resulting  anaemia. 
This  latter  condition  soon  gives  place  to  venous  con- 
gestion, and  the  continuance  of  the  insensibility  and 
the  convulsive  movements  is  to  be  explained  by  the  fact 
that  the  amount  of  oxygen  in  the  cerebral  blood  is  much 
below  the  normal  amount.  The  condition  of  the  cerebral 
veins  is  clearly  indicated  by  the  marked  cyanosis,  which 
is  due  in  great  measure  to  compression  of  the  jugular 
veins  by  the  spasmodically-contracted  muscles  of  the 
neck. 

According  to  Dr.  Hughlings-Jackson's  view  the 
epileptic  attack  originates  in  the  cerebral  cortex,  which 
contains  motor,  and  probably  also  vaso-motor,  centres. 
As  a  result  of  disturbance  of  equilibrium,  a  violent  dis- 
charge of  the  nervous  force  accumulated  in  the  ganglion 
cells  suddenly  takes  place.  If  the  motor  centres  are 
stimulated  by  pathological  processes  the  convulsions 
begin  in  the  corresponding  groups  of  muscles,  and  often 


142  FA TMOL OGY  OF  FFILFPS Y. 

extend  to  the  limb  of  the  opposite  side,  and  thence  to 
the  muscles  generally.  The  abolition  of  consciousness 
results  from  the  temporary  exhaustion  of  the  ganglion 
cells  which  follows  the  discharge. 

That  an  epileptic  attack  may  originate  in  the  cerebral 
cortex  has  been  conclusively  proved  by  experiments.  If 
the  cortical  areas  for  both  limbs  on  one  side  of  an  animal 
be  removed,  the  epileptic  attacks  which  subsequently 
occur  are  limited  to  the  muscles  of  the  head  and  face  on 
both  sides.  In  another  and  still  more  demonstrative 
experiment  general  convulsions  were  caused  in  a  dog  by 
continuous  irritation  of  a  portion  of  the  cortex.  The 
irritated  portion  was  then  removed  by  means  of  a 
horizontal  incision,  when  the  convulsions  immediately 
ceased.  Moreover,  during  an  epileptic  attack  artificially 
produced  in  a  dog,  the  motor  area  of  one  extremity  can 
be  excised  with  the  effect  of  excluding  this  limb  from 
the  attack,  while  the  convulsions  continue  in  the 
remainder  of  the  body. 

According  to  Dr.  Brown-Sequard,  the  theory  that 
epilepsy  depends  on  disease  of  any  special  part  of  the 
nervous  centres  has  not  been  established.  He  thinks 
that  the  true  seat  of  epilepsy  is  to  be  found  in  nerve- 
cells  capable  of  producing  morbid  reflex  muscular  con- 


PATHOLOGY  OF  EPILEPSY.  143 

tractions_,  and  that  these  cells  are  located  chiefly  in  the 
base  of  the  brain.  Epileptiform  convulsions  can^  how- 
ever, take  place  after  the  removal  of  the  brain,  cerebellum, 
pons  Varolii,  and  a  portion  of  the  medulla  oblongata.  It 
would,  therefore,  appear  that  the  spinal  cord  has  a  share 
in  the  production  of  epileptiform  convulsions,  "  and  as 
we  know  that  it  can  in  man,  as  well  as  in  animals, 
arrest  the  activity  of  the  brain  under  some  stimulation, 
we  may  easily  admit  that  it  may  help  in  producing  in 
man  an  arrest  of  cerebral  activity  during  a  fit  of 
€pilepsy.^^ 

We  know  nothing  with  regard  to  the  anatomical 
character  of  the  changes  in  epilepsv,  whether  located  in 
the  cortex  cerebri  or  in  the  basal  ganglia.  When  we 
speak  of  the  pathological  irritability  of  the  affected 
centres  we  use  words  which  convey  little  meaning.  The 
authority  just  quoted  does  not  think  that  alterations  in 
the  cells  will  ever  be  detected.  "  It  is  quite  likely  that 
the  change  in  them  is  more  dynamical  than  physical, 
and  that  no  more  microscopic  differences  could  be 
detected  between  two  of  them,  one  normal  and  the  other 
possessing  great  morbid  reflex  power,  than  there  are 
visible  differences  between  two  pieces  of  magnet — one 
poor,  the  other  rich  in  magnetic  power." 


144  SYMPTOMS  OF  EPILEPSY. 


With  regard  to  the  kind  of  irritant  which  excites  the 
activity  of  the  nerve-centres  our  notions  are  but  vague. 
In  cases  of  reflex  epilepsy  the  irritation  of  a  sensory 
nerve  may  well  be  the  cause  of  the  movements  ;  while 
mental  impressions  produce  excitement  in  the  cerebral 
cortex^  and  this  is  communicated  to  the  cells  in  the  base 
of  the  brain  and  in  the  upper  part  of  the  cord. 

Symptoms.  The  phenomena  of  a  typical  epileptic  fit 
are  as  follows : — After  certain  precursory  abnormal 
sensations,  or  suddenly  without  any  premonition  what- 
ever^ the  patient  turns  pale^  utters  a  loud  cry,  loses 
consciousness,  and  falls  down,  one  side  or  the  whole 
of  the  body  becomes  rigid,  and  the  breathing  ceases  for 
some  seconds.  Then  the  colour  of  the  face  changes,  it 
becomes  red,  and  finally  purplish  ;  the  eyeballs  start  from 
their  sockets,  and  clonic,  sometimes  unilateral  convul- 
sions of  the  muscles  take  place;  the  contents  of  the 
bladder  and  bowels  are  often  evacuated.  The  move- 
ments continue  for  several  minutes,  and  then  gradually 
abate  ;  the  blueness  of  the  face  passes  off,  the  limbs 
become  flaccid,  and  consciousness  returns  either  at  once 
or  after  an  interval  of  stupor  or  coma.  When  this 
latter  condition  has  passed  off  the  patient  usually 
complains  of  headache^  weariness,  and  soreness  of  the 


SYMPTOMS  OF  EPILEPSY.  145 


limbs  :  he  has  no  recollection  of  the  incidents  of  the 
attack. 

Some  of  the  phenomena  require  to  be  examined  more 
ill  detail.  The  premonitory  symptoms  differ  con- 
siderably in  their  character  and  duration.  Sometimes 
the  patient  is  conscious  of  various  alterations  of  his 
usual  state  of  feeling,  or  of  confusion  of  thou2:htj  or  of 
failure  of  memory.  At  the  present  time  I  am  treating 
a  patient  who  is  thus  warned  of  an  impending  attack. 
In  other  cases  giddiness,  headache,  drowsiness,  and  a 
feeling  of  fulness  in  the  head  are  complained  of.  Various 
disorders  of  the  special  senses,  tingling  in  different  parts 
of  the  body,  and  nausea  are  occasionally  experienced. 

Some  patients  are  able  to  predict  that  an  attack 
is  coming  on.  In  others  the  warning  is  very  short, 
perhaps  just  sufficient  to  afford  opportunity  for  the 
patient  to  place  himself  on  a  sofa  or  chair.  The 
phenomenon  termed  the  aura  epilepiica  occurs  in  a 
small  proportion  of  cases.  It  consists  of  strange 
sensations,  e.g.,  as  of  a  stream  of  cold  water  falling 
on  the  skin.  This  may  begin  in  any  part  of  the  body, 
and  it  gradually  spreads  to  the  head,  when  loss  of 
consciousness  takes  place.  Tlie  aura  may  last  for 
several  seconds,  or  even  for  some  minutes.     When  the 

10 


146  SYMPTOMS  OF  EPILIJPSY. 

attack  is  at  its  height  consciousness  is  completely 
abolished^  and  the  severest  injuries  are  unfelt  by  the 
patient.  At  the  same  time  the  reflex  excitability  is 
much  reduced;  and  in  some  cases  altogether  in  abey- 
ance. The  eyelids  do  not  close  when  the  cornea  is 
touched;  neither  do  the  pupils  contract  on  exposure  to 
strong  light.  Injuries  are  not  unfrequently  received 
during  the  fall  and  the  subsequent  convulsions.  The 
tongue^  which  is  protruded  from  the  mouthy  is  often 
badly  hurt  between  the  teeth.  Owing  first  to  the 
rigidity,  and  afterwards  to  the  irregular  contractions 
of  the  rauscleS;  respiration  is  imperfect,  and  performed 
with  difficulty;  the  glottis  is  contracted,  and  the  lungs 
are  not  fully  distended.  The  struggles  for  breath  and 
the  movements  of  the  lower  jaw  cause  the  air  to  be' 
mixed  with  saliva  and  the  mucus  of  the  mouthy  and\ 
white  or  bloody  foam  often  appears  at  the  lips.  The 
first  stage  of  the  attack,  that  of  tonic  spasm,  is  always 
the  shortest.  It  never  lasts  for  more  than  a  minute, 
and  is  sometimes  over  in  a  few  seconds.  The  clonic 
convulsions  have  a  longer  duration;  they  may  go  on  for 
several  hours,  but  their  average  length  is  from  ten  to 
fifteen  minutes.  The  urine  passed  after  their  subsidence 
sometimes  contains  albumen  and  hyaline  casts.  The 
frequency   of   the  attacks  varies    considerably.      Daily 


SYMPTOMS  OF  EPILEPSY.  147 

occurrences  are  observed  in  some  cases ;  in  others  a 
year^  or  even  several  years_,  elapse  between  the  par- 
oxysms. A  rapid  succession  of  attacks  during  several 
days  or  weeks,  follov/ed  by  a  complete  immunity  for  a 
lengthened  period,  is  not  unfrequent.  Definite  period- 
icity is  very  rarely  observed  except  in  women,  in  whom 
the  attacks  sometimes  coincide  with  the  menstrual 
periods.  In  most  cases  there  is  an  absence  of  regularity, 
and  the  attacks  come  on  quite  unexpectedly. 

It  is  somewhat  difficult  to  give  a  succinct  account  of 
the  milder  forms  of  epilepsy.  They  are  manifested  by 
occasional  attacks  in  which  consciousness  is  either 
completely  lost  or  much  diminished,  but  power  over  the 
muscles  is  generally  so  far  retained  that  co-ordinate 
movements  can  still  be  accomplished.  The  spasmodic 
element  is  wanting,  or  is  represented  only  by  a  few 
twitches.  The  symptoms  exhibited  differ  greatly  in 
different  patients.  The  unconsciousness  may  last  for 
a  few  seconds,  or  for  several  minutes.  Recently,  in 
consultation  with  Dr.  Hughlings-Jackson,  I  saw  a 
patient  in  whom  the  unconsciousness  lasted  only  a  few 
seconds,  and  sev^eral  similar  cases  in  persons  of  both 
sexes  have  come  under  my  notice.  During  its  con- 
tinuance automatic  actions,  e.g.,  walking,  painting,  etc.^ 
may   still   be  performed.      In  other  cases  the    patient 


148  IRREGULAR  FORMS  OF  JEPILEPSY. 

Stops  suddenly  when  talking,  stares  vacantly  for  a  few 
moments,  and  then  finishes  his  sentence  without  any 
further  difficulty.  If  these  and  similar  slight  attacks 
occur  when  the  patient  is  sitting  or  lying  down  they 
may  pass  off  almost  without  notice.  In  cases  of  a  more 
severe  form  the  loss  of  consciousness  is  complete  and 
more  prolonged.  The  patient  falls  down,  perhaps  when 
walking,  and  remains  unconscious  for  several  minutes. 
Giddiness  is  sometimes  complained  of,  especially  when 
the  loss  of  consciousness  is  not  complete.  Partial 
convulsions,  as  of  a  few  muscles  of  the  face,  arm,  or 
hand/ are  noticed  in  some  cases. 

Attacks  as  above  described  are  included  under  the 
term  ''  epilepsy  "  for  the  following  reasons  : — They 
sometimes  precede  the  more  severe  paroxysms,  and 
sometimes  alternate  with  them.  They  are  often 
ushered  in  by  the  precursory  symptoms  of  the  graver 
attacks,  and  are  followed  in  some  cases  by  drowsiness 
and  stupor.  Moreover,  as  regards  severity  of  symptoms, 
epilepsy  presents  innumerable  grades  between  the 
mildest  and  the  most  violent,  and  the  various  "abor- 
tive "  forms  of  the  disorder  pass  by  imperceptible 
degrees  into  the  pronounced  type. 

Other  irregular  forms  of  attack  are  sometimes 
noticed.     It  occasionally  happens  that  the  convulsions 


IB  RE  G  ULA  R  FORMS  OF  FPILEPS  Y.  1 49 

are  somewhat  violent_,  while  consciousness  and  sen- 
sation arc  but  very  slightly  affected.  On  the  other 
hand^  the  convulsions  may  be  absent^  their  place  being 
taken  by  co-ordinate  movements  of  walking  or  running. 
In  a  case  recently  brought  to  my  notice^  a  young  man, 
who  suffered  from  ordinary  epileptic  attacks  of  a  very 
severe  character^  would  sometimes  in  a  state  of  un- 
consciousness rush  out  of  the  house  and  run  up  and 
down  the  main  street  of  the  village  until  he  fell  from 
exhaustion.  In  other  cases  the  paroxysms  are  from 
time  to  time  replaced  by  various  forms  of  mental 
disorder.  These  symptoms,  when  of  a  severe  type, 
resemble  those  of  acute  mania.  Like  the  convulsive 
attack,  they  come  on  suddenly,  and  after  their  sub- 
sidence the  patient  has  no  recollection  of  what  has 
occurred.  Conditions  of  this  kind  sometimes  follow 
the  paroxysm,  and  the  mental  affection  may  last  for 
several  days.  In  a  less  marked  form,  the  utmost 
variety  may  be  presented  by  the  symptoms.  Acts  of 
senseless  violence,  acts  indicative  of  mental  confusion, 
of  complete  disregard  of  decency,  etc.,  would  appear  in 
some  cases  to  replace  the  convulsive  paroxysms.  After 
the  accomplishment  of  the  acts  the  patients  are 
ignorant  of  what  has  occurred,  and  express  more  or  less 
surprise  when  the  details  are  related  to  them. 


I50  i:pili:ptoid  states. 

A  full  description  of  the  so-called  epileptoid  states 
would  transgress  the  limits  which  the  author  has 
prescribed  for  himself.  To  classify  the  conditions  thus 
designated  would  be  a  task  of  much  difficulty,  more 
especially  as  authors  are  by  no  means  agreed  as  to  the 
boundaries  of  the  definition.  Nothnagel's  explanation 
is  as  follows :  "  Those  states  should  be  regarded  as 
epileptoid,  i.e.,  as  caused  by  a  central  epileptic  change, 
in  which  symptoms  show  themselves  paroxysmally,  for 
the  development  of  which  the  same  physiological  pro- 
cesses, according  to  our  present  knowledge,  should,  or 
at  any  rate  may  be  assumed,  as  produce  (when  deve- 
loped in  greater  intensity  or  extent)  the  usual  epileptic 
attacks.  .  .  .  The  certainty  as  to  whether  the  case  be 
one  of  genuine  epilepsy  or  not  is  to  be  gathered  from 
the  occurrence,  sooner  or  later,  of  real  paroxysms  in 
place  of  or  alternating  with  these  questionable  seizures." 

The  main  clinical  features  of  the  epileptoid  states  are 
attacks  of  giddiness  and  abnormal  sensations  of  various 
kinds,  which  when  associated  with  corresponding 
mental  symptoms  more  or  less  closely  resemble  the 
phenomena*  of  hysteria  and  hypochondriasis.  Such 
conditions  may  easily  pass  into  real  mental  disorder, 
paroxysms  of  which  take  the  place  of  the   convulsive 


BE  FLEX  E  PILE  PS  1'.  151 

attacks.  The  attacks  of  giddiness  are  the  most 
characteristic.  Nothnagel  cites  the  case  of  a  clergy- 
maiij  in  whom  frequently  recurring  attacks  of  vertigo, 
extending  over  some  years_,  were  succeeded  by  others  in 
which  there  was  complete  loss  of  consciousness  and 
muscular  rigidity.  Other  cases  recorded  by  the  same 
author  presented  totally  different  symptoms_,  e.g., 
obscuration  of  the  visual  fields  the  supervention  of  a 
kind  of  dreamy  condition_,  lasting  for  some  time, 
during  which  sight  and  hearing  were  more  or  less 
disturbed,  and  hallucinations  of  the  most  varied  kind. 
The  paroxysmal  character  of  these  phenomena,  and  their 
occurrence  in  persons  exhibiting  from  time  to  time 
other  symptoms  more  commonly  referred  to  epilepsy 
are  regarded  as  sufficient  reasons  for  connecting  them 
with  this  disease. 

There  are  certain  forms  of  epilepsy  which  yet 
remain  to  be  noticed.  The  most  important  of  these 
are:  epilepsy  of  reflex  origin  and  the  so-called  '^Jack- 
sonian "  epilepsy.  The  condition  termed  hystero- 
epilepsy  has  been  already  described  in  the  chapter 
on    hysteria. 

The  term  reflex  epilepsy  is  applied  to  those  forms  of 
the  disorder   in  which   some  anatomical  lesion  of  the 


152  J  A  CKS  ONI  A  N  JEPILi:PS  Y. 

peripheral  nerves  has  caused  the  development  of  the 
symptoms.  The  course  of  events  in  a  case  of  this 
kind  is  somewhat  as  follows :  The  patient  receives  an 
injury,  such  as  a  wound  on  any  part  of  the  body,  but  in 
most  cases  on  one  of  the  extremities.  Healing  takes 
place,  and  perhaps  nothing  more  is  thought  of  the 
wound  j  after  an  indefinite  interval  painful  sensations 
are  experienced  in  the  cicatrix,  and  twitchings  in  the 
neighbouring  muscles  begin  to  be  noticed.  In  some 
recorded  cases  a  feeling  of  numbness  preceded  the 
twitchings.  These  movements  become  more  and  more 
troublesome,  and  extend  in  an  upward  direction  to 
other  muscles.  The  feelins;  of  discomfort  likewise 
spreads  towards  the  head,  and  finally  provokes  an  attack 
of  epilepsy.  This  recurs  from  time  to  time,  and  can 
generally  be  excited  by  irritating  the  cicatrix.  It  is  in 
these  cases  that  a  paroxysm  can  sometimes  be  averted 
by  applying  a  ligature  or  tourniquet  to  the  limb  above 
the  cicatrix,  whence  the  epileptic  aura  proceeds. 

That  secondary  form  of  the  disorder  which  has  been 
termed  ''  Jacksonian  epilepsy  "  is  connected  with  the 
presence  of  lesions  in  the  cerebral  cortex.  The  convul- 
sions occur  on  the  opposite  side  of  the  body,  and  may  be 
limited  to  certain  groups  of  muscles,  to  a  limb,  to  the 


COURSJE  OF  EPILEPSY. 


153 


head  or  neck.  After  each  attack  a  paretic  condition  is 
apt  to  be  set  up  in  the  affected  muscles;  this  at  first  is 
of  a  temporary  character^  but  it  sooner  or  later  becomes 
permanent^  and  finally  merges  into  complete  paralysis. 
The  convulsive  movements  come  on  at  very  uncertain 
intervals^  and  they  may  be  altogether  absent  for  long 
periods.  They  are  generally  unattended  by  loss  of  con- 
sciousness^ and  this  symptom,  when  present,  is  less 
marked  than  in  cases  of  typical  epilepsy. 

The  course  of  the  disorder  varies  greatly  in  different 
cases.  It  is  generally  chronic,  and  not  a  few  epileptic 
patients  live  to  a  somewhat  advanced  age,  without 
exhibiting  any  material  impairment  of  their  bodily  or 
mental  faculties.  Even  the  frequency  and  severity  of 
the  paroxysms  are  not  of  such  ominous  import  as  was 
formerly  supposed.  Only  in  very  rare  cases  do  the 
paroxysms  terminate  fatally  in  consequence  of  cerebral 
haemorrhage  or  from  apnoea.  The  majority  of  fatal 
cases  are  caused  by  accidents  of  various  kinds,  to  which 
epileptics  are  peculiarly  liable.  Accidental  death  from 
fallino^  into  fire  or  water  or  from  a  hei2;ht  is  not  an  un- 
frequent  occurrence. 

In  about  forty  per  cent,  of  all  cases  of  epilepsy,  indi- 
cations of  mental  disorder  sooner  or  later  exhibit  them- 


154  MJENTAL  DISORDER  IN  I:PIL:EPSY. 

selves.  After  these  have  appeared  the  patient's  con- 
dition invariably  becomes  worse  and  worse.  For  some 
time  the  general  health  between  the  convulsive  attacks 
may  appear  to  be  perfectly  good,  and  a  very  close 
•  examination  maybe  required  to  discover  any  signs  of 
derangement.  Constant  pain  in  the  head,  a  feeling  of 
confusion,  inability  to  fix  the  attention  continuously  on 
any  given  subject,  and  frequent  muscular  twitchings  are 
the  most  common  evidences  of  incipient  deterioration. 
Certain  mental  peculiarities  are  likewise  apt  to  become 
prominent.  In  some  patients,  without  obvious  cause, 
excitement  alternates  with  depression;  marked  obsti- 
nacy and  capriciousness  are  sometimes  exhibited  j  in 
other  cases  the  memory  becomes  deficient,  and  mental 
exertion  is  felt  to  be  more  and  more  irksome.  As  time 
goes  on,  the  signs  of  deterioration  become  more  obvious  ; 
not  only  are  the  paroxysms  more  frequent,  but  the 
condition  during  the  intervals  changes  for  the  worse. 
All  the  intellectual  powers  become  more  or  less  im- 
paired. In  some  cases  violent  attacks  of  mania  con- 
stitute the  prevailing  feature;  in  others  the  patient 
relapses  into  a  state  of  dementia.  Under  such  circum- 
stances the  features  and  manner  of  the  patient  are  con- 
siderably   changed,    and    the    animal    propensities    are 


DIAGNOSIS  OF  EPILEPSY.  155 

wont  to  become  \^ery  prominent.  A  condition  of 
imbecility  is  the  last  stage  of  the  disorder,  and^  in  the 
absence  of  organic  disease  in  the  chest  or  abdomen^ 
may  continue  for  many  years. 

Diagnosis.  The  affections  with  which  epilepsy  is 
likely  to  be  confounded  are  apoplexy,  syncope  from 
cardiac  weakness,  hysteria,  and  convulsions  occurring  in 
children. 

An  ordinary  epileptic  attack  can  be  easily  distin- 
guished from  apoplexy.  The  violent  convulsions  of  the 
former  contrast  strongly  with  the  motionless  phase  of 
the  latter.  '  When,  however,  the  paroxysm  is  over  and 
profound  coma  has  supervened,  there  may  be  some 
difficulty  in  distinguishing  between  the  two  conditions, 
especially  when  the  previous  history  cannot  be  obtained. 
The  appearance  of  foam  mixed  with  blood  about  the 
mouth,  the  absence  of  paralysis  and  of  stertorous 
breathing  are  usually  sufficient  to  determine  the  diag- 
nosis, but  it  may  be  necessary  to  watch  the  case  for 
some  little  time  before  coming  to  a  positive  conclusion. 

Attacks  of  faintness  may  be  mistaken  for  epilepsy. 
In  the  former,  however,  the  loss  of  consciousness  is,  as 
a  general  rule,  not  sudden,  but  gradual,  and  preceded  by 
a  feeling  of  depression  or  nausea.     There  are  no  con- 


1 5  6  DIA  GNOSIS  OF  E  PILE  PS  Y. 


vulsions^  and  no  involuntary  discharges^  and  the  patient 
after  recovery  feels  anxious  and  giddy^  but  not  lethargic. 
His  condition^  moreover,  is  relieved  by  stimulants. 
Until  thoroughly  recovered  his  face  continues  pale. 

The  diagnosis  between  epilepsy  and  hysteria  has  been 
given  in  a  previous  chapter  (see  p.  113).  It  is  only 
necessary  to  add  that  it  has  become  more  difficult  to 
distinguish  between  the  two  affections  since  we  have 
learnt  to  recognize  hystero-epilepsy  as  a  connecting 
link  between  them.  The  loss  of  consciousness  was 
thought  to  be  characteristic  of  epilepsy,  but  this  may 
also  occur  in  the  mixed  disorder.  The  abolition  of 
reflex  movements  points  decidedly  to  epilepsy,  but  the 
latter  may  exist  in  the  absence  of  this  symptom.  The 
more  any  given  attack  differs  from  the  typical  form^  the 
greater  the  difficulty  of  diagnosis. 

Convulsions  in  children,  whether  arising  from  intes- 
tinal irritation  or  other  similar  cause,  or  occurring 
■during  the  course  of  a  febrile  affection,  may  so  closely 
resemble  epilepsy  as  to  be  incapable  of  being  distin- 
guished from  it.  If  the  convulsions  passed  away  after 
the  removal  of  the  cause,  it  would  be  unnecessary  to 
refer  them  to  the  state  in  question,  but  if  they  recurred 
from  time  to  time,  the  child's  health  being  good  in  the 


PEOGNOSIS  OF  EPILEPSY. 


157 


interval,  they  might  justly  be  classified  as  epileptic. 
Whether  the  ^'  epileptic  change  ^'  had  taken  place  or  not 
could  be  determined  only  by  the  subsequent  history  of 
the  case. 

Epilepsy  is  occasionally  feigned_,  and  a  clever  impostor 
who  has  carefully  studied  its  most  striking  phenomena 
may  easily  deceive  all  but  a  well -practised  observer. 
There  are,  however,  certain  symptoms  u^hich  cannot  be 
counterfeited,  viz.,  the  initial  pallor  of  the  face,  the 
dilatation  of  the  pupil,  the  insensibility  of  the  eye  to 
light,  the  changes  in  the  pulse,  and  the  ultimate  pur- 
plish or  livid  hue  of  the  face.  In  a  real  epileptic  patient 
there  are  often  marks  of  injury  on  the  face  or  hands, 
resulting  from  falls  in  previous  attacks,  and  likewise 
scars  on  the  tongue.  The  impostor  generally  chooses  a 
convenient  place  for  falling,  and  his  attacks  always 
occur  in  the  presence  of  others.  He  sometimes  produces 
the  foam  at  the  mouth  by  means  of  a  piece  of  soap.  A 
London  policeman  has  been  known  to  expose  the 
counterfeiter  by  wrenching  open  his  mouth  and  re- 
moving the  source  of  the  foam. 

Frognos'is.  Epilepsy  is  a  very  serious  disease,  and 
rarely  admits  of  a  favourable  prognosis.  The  abortive 
attacks  are  less  amenable  to  treatment  than  the  ordinary 


158  Fit  O  GNOSIS  OF  FFILFFSY. 

type  of  the  complaint.  As  a  general  rule  it  may  be 
stated  that  permanent  recovery  takes  place  in  about  five 
per  cent,  of  all  cases.  It  is^  however^  often  possible  to 
reduce  the  severity  and  frequency  of  the  attacks  by 
proper  treatment,  but  the  improvement  is  generally  of 
temporary  character.  In  not  a  few  cases  the  progress 
of  the  disease  appears  to  be  unchecked  by  any  remedies. 
When  a  marked  hereditary  tendency  is  present,  either 
to  the  disease  itself  or  to  other  forms  of  nervous  dis- 
order, the  prognosis  is  always  very  unfavourable.  In 
the  absence  of  any  such  tendencies,  and  when  the 
attacks  occur  in  a  patient  under  20  who  appears  per- 
fectly well  during  the  intervals,  there  is  much  room  for 
hope  that  recovery  may  take  place.  The  longer  the 
complaint  continues  the  more  likely  is  it  to  prove 
irremediable.  Recovery  is  almost  out  of  the  question 
if  the  mind  has  become  impaired,  or  if  any  symptoms 
of  paralysis  are  present.  As  in  other  forms  of  nervous 
disorder,  it  not  unfrequently  happens  that  a  change  in 
the  treatment  is  attended  with  apparent  benefit,  and  the 
same  result  often  follows  any  change  for  the  better  in 
the  patient's  surroundings.  The  mental  condition  of 
the  patient  always  exerts  more  or  less  influence  on  the 
progress  of  the  complaint. 


TREATMENT  OF  EPILEPSY.  159 

Treatment.     In  dealing  with  a  case  of  epilepsy  every 
endeavour  shoidd  be  made  to  discover  any  possible  cause 
of   the' disorder.     Remedies   should  not   be  used  in  a 
haphazard  fashion,  but  the  state  of  the  system  and  any 
irregularity  of  function  should   be  carefully    observed. 
Subject   to    these    general    provisions    the    treatment 
divides  itself  into  that  which  is  required  in  the  intervals 
and  that  which  is  adapted  to  the  paroxysms.     Cases  of 
reflex  epilepsy  are  sometimes  very  amenable  to  treat- 
ment.    The  removal  of  cicatrices,  includins:  fibrils    of 
nerves^  which  formed  the  starting-point  of  the  aura^  has 
been  followed  by  the  happiest  results.     In  another  class 
of  cases  a  cure  has  been  effected  by  the  operation  of 
trephining,  whereby   diseased    portions    of    the    skull, 
exostoses,    or    spicula  of  bone  were   removed.     As    a 
matter  of  course  improvement  is  not  an  invariable  result 
even  where  the  cause  of  the  disease  has  thus  been  re- 
moved ;  the  changes  in  the  central  organs  set  up  bv  the 
irritation  at  the  periphery  are  apt  to  become  permanent 
and  independent  of  the  lesion  w  hich  originally  produced 
them.     The  lesson  to  be  drawn  from  the  success  which 
has  been  obtained  in  such  cases  is  that  every  epileptic 
patient   should  be  very  carefully  examined   in  order  to 
learn  whether  any  peripheral  causes   of  irritation,  such 


i6o  te:eatmi:nt  of  epilepsy. 

as  cicatrices,  exostoses,,  necrosed  bone,  etc.,  are  dis- 
coverable. The  examination  should  not  be  confined  to 
the  superficial  parts,  but  should  extend  to  all  the  organs 
of  the  body,  and  especially  to  the  lungs,  stomach, 
ovaries,  and  uterus. 

The  general  state  of  the  patient  should  next  be  con- 
sidered, and  any  deviation  from  the  healthy  condition 
should  be  remedied  as  far  as  possible.  If  the  patient  be 
plethoric,  saline  purgatives  and  a  restricted  diet  are 
indicated.  Anaemic  cases  will  be  benefited  by  iron, 
quinine,  a  nutritious  diet,  and  a  general  tonic  regimen. 
The  condition  of  the  digestive  organs  should  receive 
especial  attention ;  constipation  in  particular  should  be 
corrected  by  appropriate  remedies.  Symptoms  of  gastric 
catarrh  when  present  will  require  alkalies  and  vegetable 
bitters,  and  the  possibility  of  tape-worm  being  the 
exciting  cause  of  the  attacks  should  not  be  forgotten. 

In  the  treatment  of  confirmed  epilepsy  the  regulation 
of  the  diet  and  of  the  patient's  general  habits  is  of  the 
utmost  importance.  The  rules  to  be  laid  down  in  these 
particulars  must,  of  course,  be  adapted  to  each  individual 
case;  only  general  principles  can  here  be  given.  In 
the  first  place  excesses  of  every  kind  must  be  abandoned. 
The    diet    should   be   nutritious    and    non-stimulating; 


TREA  TMENT  OF  E  PILE  PS  Y.  1 6 1 

especial  attention  should  be  paid  to  the  quantity  of 
animal  food,  for,  as  a  general  rule^  the  attacks  becoine 
more  frequent  when  articles  of  this  description  are  too 
largely  used.  Some  patients  are  improved  by  a  diet 
consisting  principally  of  vegetables  and  milk.  Regular 
and  moderate  occupation,  exercise  short  of  fatigue,  early 
hours,  in  fact,  hygienic  measures  of  all  kinds,  are 
indispensable  for  the  satisfactory  treatment  of  an 
epileptic  patient ;  if  they  cannot  be  secured  drugs  will 
prove  of  little  or  no  avail. 

An  enormous  number  of  remedies  have  been  recom- 
mended for  epilepsy,  but  the  reputation  acquired  by 
most  of  them  has  been  only  of  a  temporary  character. 
A.t  the  present  day  the  bromide  of  potassium  is  the 
remedy  which  yields  the  best  results;  it  is,  however, 
sometimes  useless,  but  it  always  deserv^es  a  thorouc^h 
trial,  for  though  it  may  fail  to  cure  the  disease  it  will 
generally  cause  more  or  less  improvement.  Diminished 
frequency  of  the  paroxysms  and  improvement  in  the 
mental  condition  of  the  patient  are  results  which  are 
often  witnessed.  To  afford  any  prospect  of  success 
it  must  be  given  in  full  doses,  viz.,  from  one  up  to 
three  or  even  four  drachms  per  day.  A  convenient 
method  of  exhibiting  it  is  to  dissolve  it  in  seltzer-water 

II 


i62  TREATMENT  OF  BPILEPSY. 

or  niilk_,  and  sometimes  it  is  better  tolerated  by  the 
stomach  if  taken  with  some  bitter  infusion  and  a  few 
grains  of  bicarbonate  of  potassium.  Concentrated 
solutions  of  these  large  doses  should  never  be  employed^ 
as  they  are  apt  to  irritate  the  stomach.  To  obtain  the 
full  effects  of  the  drug  it  should  be  given  for  two  or 
three  months ;  if  no  improvement  take  place  its 
administration  should  be  stopped.  It  must  not  be 
forgotten  that  prolonged  use  of  the  bromide  of  potas- 
sium is  apt  to  be  followed  by  very  untoward  results, 
such  as  a  condition  of  utter  passiveness,  lethargy,  and 
inability  to  perform  any  mental  operations.  If  there 
be  any  appearance  of  these  symptoms  the  use  of  the 
drug  should  be  disconthiued,  and  we  may  then  have 
recourse  to  atropine.  This  powerful  drug  should  be 
given  in  doses  commencing  with  the  yj^^  of  a  grain, 
gradually  increased  up  to  -gV,  or  even  ^q.  The  quantity 
prescribed  should  be  administered  in  a  single  dose  at 
bed-time,  and  slowly  increased,  week  by  week,  until 
the  maximum  is  reached.  This  is  to  be  continued  for 
a  fortnight,  and  then  steadily  reduced  to  the  minimum 
dose.  This  plan  of  treatment  may  be  persevered  in  for 
a  year  or  more,  the  patient,  of  course,  being  very  care- 
fully watched  during  the  whole  time,  and  the  medicine 
stopped  on  the  appearance  of  any  toxic  symptoms. 


TREATMJENT  OF  JEPILBPST.  163 

Other  remedies  used  for  epilepsy  require  only  a  brief 
notice.     The  oxide  of  zinc_,  nitrate  of  silver,  and  the 
ammonio-sulphate   of  copper,    although    much   lauded 
from  time  to  time  by  various  authorities,  would  seem  to 
possess  little,  if  any,  real  efficacy.     They  may,   how- 
ever, be  tried  if  the  bromide  and  atropine  prove  useless. 
They  are  supposed  to  strengthen  the  nervous  system, 
and  to    lessen  abnormal  excitability.      The  nitrate  of 
silver  is  given  in  doses  of  one-quarter  or  one-third  of  a 
grain  three  times  a  day,  to  be  gradually  increased  to 
one  or  even  two  grains.     It  is  best  administered  in  a 
pill,  with  kaolin  ointment  as  an  excipient.     The  risk 
of  permanent  discoloration  of  the   skin   should  always 
be  borne  in  mind;  the    remedy  should  never  be  con- 
tinued longer  than  six  weeks  or  two  months  without 
an  intermission  of  an  equal  length.     The  oxide  of  zinc, 
to  be   of  any  use,  must  be  given  in  large  doses,  but 
these  are  not  always  tolerated  by  the  stomach.     From 
two  grains  at  first,  three  times  a  day,  in  the  form  of  a 
pill,  the  dose  may  be  increased  up  to  ten,  fifteen,  or 
even  twenty  grains'  in  the  absence  of   marked  gastric 
symptoms.     The  sulphate  of  copper  is  given  in  doses 
of  from  half-a-grain  to  two  grains,  and  the  ammoniated 
copper  in  doses  of  from  one  to  five  grains.     The  latter 
drug  is  said  to   be  more  efficacious   in  adults  than  in 


1 64  t:ri:a  tment  of  i:filjep8  y. 

children;  the  reverse  holds  good  with  regard  to  zinc. 
It  is  also  said  to  be  more  suitable  for  torpid^  phlegmatic 
persons  than  for  those  of  an  irritable,  nervous  tempera- 
ment. Many  vegetable  remedies  have  been  employed 
in  the  treatment  of  epilepsy ;  some  for  their  tonic, 
others  for  their  antispasmodic  properties,  and  others, 
again,  have  been  given  quite  empirically.  Of  the  vege- 
table tonics  quinine  is  worthy  of  trial  when  the  attacks 
assume  a  decidedly  periodical  form ;  it  may  also  be 
given  with  the  view  of  improving  the  digestion.  Among 
the  antispasmodics  valerian  is  one  of  the  oldest  reme- 
dies. Its  real  efficacy  may  be  doubted  ;  yet  it  would 
appear  to  possess  some  power  of  lessening  nervous 
excitability.  In  some  experiments  made  a  few  years 
ago  upon  frogs  the  administration  of  oil  of  valerian 
(gr.  -\)  was  found  to  produce  a  quiet  and  apathetic 
state,  followed  by  complete  stupor.  Reflex  irritability 
was  considerably  diminished,  and  the  change  appeared 
to  depend  upon  an  influence  affecting  the  spinal  cord, 
as  well  as  the  spasm-centres  in  the  brain.  The  drug 
would  seem  to  be  best  adapted  for  cases  of  hystero- 
epilepsy ;  its  infusion  will  also  serve  as  a  vehicle  for 
the  bromide  of  potassium.  Of  the  purely  empirical 
remedies    it    is    sufficient    to    mention    the    cotyledon 


TREATMENT  OF  EPILEPSY.  165 

umbilicus,  indigo,  sumbul,  and  artemisia  vulgaris. 
These  and  many  other  drugs  are  said  to  have  effected 
improvement,  and  even  cures  in  some  cases.  It  is 
probable  that  any  change  for  the  better,  observed  after 
their  use,  has  been  due  mainly  to  the  influence  of 
novelty  or  hope  on  the  mind  of  the  patient,  and  to 
alterations  in  his  manner  of  living  enjoined  by  the 
physician  when  prescribing  the  drugs. 

Electricity  in  various  forms  has,  of  course,  been  tried 
for  epilepsy,  and  cures  are  said  to  have  been  effected. 
We  know  nothing  of  the  special  conditions  for  which 
electricity  would  be  likely  to  be  serviceable,  but  it  may 
be  tried  as  an  auxiliary  to  other  means.  A  galvanic 
current  of  moderate  strength  is  employed  ;  the  electrodes 
are  placed  one  on  each  side  of  the  upper  part  of  the 
back  of  the  neck^  or  over  the  course  of  the  cervical 
sympathetic  nerves.  Currents  may  also  be  sent  through 
the  cranium;  and  whenever  a  decided  aura  follows  the 
course  of  a  nerve,  it  has  been  recommended  to  apply 
the  electrodes  to  the  surface  in  relation  therewith.   . 

Hydro-therapeutic  treatment  may  sometimes  be  advan- 
tageously conjoined  with  other  remedies  for  epilepsy. 
The  patient  should,  as  Nothnagel  recommends,  be  sent 
to  an  institution  where  the  treatment  can  be  methodi- 


1(66  TREATMENT  OF  EPILEPSY. 

cally  carried  out  for  six  or  eight  weeks^  or  even  longer. 
It  must,  of  course,  be  carefully  adapted  to  the  condition 
of  the  patient ;  violent  douches  to  the  head  and  spine 
should  be  prohibited.  Whenever  there  is  great  nervous 
excitement  tepid  or  warm  baths  may  take  the  place  of 
more  decided  measures.  In  cases  in  which  there  is 
pain  or  tenderness  along  the  spine  the  application  of 
Dr.  Chapman's  ice-bags  is  likely  to  be  serviceable. 

Little  treatment  Is  generally  required  during  the 
paroxysm.  In  cases  attended  with  the  epileptic  aura 
it  has  been  recommended  to  apply  a  ligature  or  a  tourni- 
quet to  the  limb,  and  some  patients,  when  time  will' 
allow,  are  able  to  avert  a  paroxysm  by  inhaling  ammonia 
and  other  nervine  stimulants,  or  by  taking  a  draught  of 
cold  water.  In  the  Fractitioner  for  October,  t868.  Dr. 
Buzzard  has  recorded  several  cases,  w^hich  show  that 
when  a  marked  local  sensation  precedes  an  attack,  the  fits 
may  be  diminished,  and  sometimes  even  cured  by  apply- 
ing a  narrow  blister  round  the  limb  above  the  starting- 
point  of  the  aura.  The  Inhalation  of  amyl-nitrlte  would- 
seem  to  be  a  rational  means  of  keeping  off  the  attack  In 
cases  in  which  there  is  sufficient  warning  of  Its  approach, 
and  whenever  decided  pallor  of  the  face  is  the  first  sym- 
ptom. .  During  the  paroxysm  Itself  the  patient  should  be 


TREATMENT  OF  EPILEPSY.  167 

placed  on  his  back^  with  his  head  somewhat  raised  ;  the 
clothes  should  be  loosened,  especially  about  the  neck  and 
trunk,  fresh  air  should  be  freely  admitted,  and  a  piece 
of  soft  wood  or  cork  placed  between  the  teeth  in  order  to 
prevent  the  tongue  from  being  bitten.  The  convulsive 
movements  should  be  so  far  restrained  as  to  keep  the 
patient  from  injuring  himself.  Toward  the  end  of  the 
attack  the  mucus  which  may  have  accumulated  about 
the  mouth  should  be  wiped  off.  In  the  majority  of 
cases  the  attack  spontaneously  subsides  in  a  few 
minutes,  and  the  patient  falls  into  a  deep  sleep.  If  the 
convulsions  recur  and  a  high  temperature  exists,  cup- 
ping to  the  back  of  the  neck,  or  even  the  abstraction  of 
a  few  ounces  of  blood  from  the  arm,  would  seem  to  be 
the  best  treatment.  For  very  violent  and  oft-repeated 
paroxysms  the  inhalation  of  chloroform  should  be  care- 
fully tried,  or  twenty  grains  of  chloral  hydrate  may  be 
administered  in  an  enema. 


CHAPTER  VI. 

CHOREA— ST.    VITUS'    DANCE. 


Chorea,  Historical  Notices,  Definition  and  Geographical  Dis- 
tribution OF  the  Disorder — Causes — Hereditary  Predis- 
position— Imitation — Age  and  Sex— Mental  Excitement — 
Reflex  Causes — Ocular  Disorders,  Dr.  Stevens'  Views — 
Connection  between  Rheumatism  and  Chorea — Nature  of 
Chorea — Drs.  Broadbent,  Kirkes,  and  Dickinson's  Views — 
Dr.  Strumpell's  Opinion  that  Chorea  is  a  Functional 
Disorder — Symptoms — Evidences  of  Mental  Disorder — 
Differences  in  Severity — Analysis  of  Prominent  Symptoms 
— Duration  of  the  Disorder — Prognosis,  Diagnosis,  and 
Treatment — Necessity  of  Inquiring  into  Cause — Specific 
Remedies,  as  Arsenic,  Zinc,  and  Strychnine — Cold  to  the 
Spine — Chloral — Isolation  from  other  Children. 


Chorea  is  in  many  respects  one  of  the  most  interest- 
ing disorders  which  the  physician  has  to  study.  The 
name  was  originally  given  to  the  epidemic  of  dancing 
madness  which  appeared  in  the  14th  and  15th  centuries 
in  some  parts  of  Western  Germany^  because  the  move- 
ments were  supposed  to  be  cured  by  the  help  of  St. 
Vitus,  called  "  Guy ""  in  France^  and  "  Veit "  in 
Germany.  The  same  word  (chorea)  was  subsequently 
used  by  Sydenham  to  describe  the  spasmodic  disorder 
now  universally  known  under  that  name  3    and  after- 


NOTICES  OF  CHOREA.  169 

wards  a  distinction  began  to  be  made  between  the 
chorea  Germanorum^  or  chorea  magna^  as  it  was  called, 
and  chorea  Anglorum,  or  minor. 

The  two  disorders  thus  grouped  under  a  common 
name  are  completely  distinct,  and  have  really  nothing  in 
common. 

At  the  present  day,  when  epidemics  of  the  dancing 
mania  are  unknown,  the  term  chorea  signifies  a  nervous 
affection  characterized  by  incoherent  action  of  the 
muscles.  It  may  be  more  fully  defined  as  a  convul- 
sive disorder,  most  often  occurring  in  early  life,  and 
marked  by  irregular  non-rhythmical  contractions  of  the 
voluntary  muscles,  at  first  usually  of  one  side  of  the 
body,  but  afterwards  becoming  general;  the  face  and 
arm  are  niore  frequently  affected  than  the  leg.  There  is 
no  loss  of  consciousness,  but  the  will  is  incapable  of  pre- 
venting the  movements,  which,  however,  cease  duri no- 
sleep.  As  time  goes  on  the  affected  muscles  become 
enfeebled,  the  sensibility  is  sometimes  diminished,  and 
there  is  often  impairment  of  some  special  sense. 

We  have  no  means  of  judging  whether  this  disorder 
existed  in  ancient  times ;  the  works  of  the  earlier 
writers  contain  no  descriptions  which  can  be  applied 
exclusively  to  chorea.  The  affection  was  well  known 
in   the    i8th   century,  and   often  described    by  medical 


17©  CAUSES  OF  CHOREA. 

writers  throughout  Europe.  With  regard  to  its  geo- 
graphical distribution^  chorea  is,  like  many  other  affec- 
tions of  the  nervous  system,  a  disorder  of  civilized  life^ 
Scarcely  any  part  of  the  world  is  altogether  free  from  it, 
but  it  is  far  less  common  in  tropical  countries  than  in 
the  temperate  zones.  It  is  said  to  be  about  equally 
distributed  in  the  temperate  portions  of  Europe  and 
America;  to  be  very  rare  indeed  in  the  East  and  West 
Indies,  and  almost  unknown  in  China. 

The  causes  of  chorea  are  many  in  number  and  various 
in  character.  Hereditary  predisposition  to  nervous  dis- 
orders is  a  very  Important  factor,  and  the  frequency 
with  which  it  can  be  traced  is  a  measure  of  the  relation- 
ship which  exists  between  many  affections  of  the  nervous 
system.  Epilepsy  or  hysteria  in  the  parents  predisposes, 
the  children  to  chorea.  It  must,  however,  be  re- 
membered that  when  several  children  of  the  same 
family  suffer,  the  development  of  the  symptoms  may 
be  due  to  imitation.  Small  epidemics,  indeed,  have  been 
known  to  arise  in  institutions  for  children  after  a  case 
of  chorea  had  been  admitted.  Under  such  circum- 
stances the  complaint  very  quickly  spreads,  and  its. 
progress  can  be  checked  only  by  separation.  In  these 
respects  it  is  analogous  to  hysteria.  With  regard  to 
age  and  sex,  the  majority  of  cases  occur  between  the 


CAUSES  OF  CHOREA. 


ages  of  6  and  15;  the  disorder  is  more  common  in 
girls  than  in  boys_,  the  proportion  being  three  of  the 
former  to  two  of  the  latter.  The  complaint  is  more 
often  met  with  in  towns  than  in  country  places,  and 
among  children  of  the  poor  than  among  those  of  the 
rich.  A  very  common  predisposing  cause  is  debility, 
especially  when  due  to  neglect  and  want  of  proper  food. 
Chorea  very  seldom  occurs  for  the  first  time  in  persons 
over  20  years  of  age.  Among  the  direct  causes  the 
most  potent  is  some  form  of  mental  excitement,  such 
as  fright  or  a  severe  shock.  Many  cases  are  on  record 
in  which  the  symptoms  have  followed  immediately  upon 
some  sudden  alarm.  Last  year  I  treated  a  patient  in 
whom  the  attack  was  induced  by  shock  consequent  on 
being  run  away  with  in  a  carriage.  Other  causes  are  of  a 
reflex  nature,  e.g.,  worms  in  the  intestines,  painful  affec- 
tions of  the  mouth  or  teeth,  and  disorders  of  the  genital 
functions.  I  am  now  attending  a  woman,  aged  28,  in 
whom  a  retroverted  womb  seems  to  be  the  cause  of  the 
attack.  Symptoms  occasionally  appear  in  pregnant 
women,  and  subside  after  delivery.  As  illustrating  the 
manifold  character  of  reflex  causes,  it  may  be  mentioned 
that  hemichorea  has  been  known  to  be  associated  with 
fissure  of  the  anus.  The  movements  completely  ceased 
after  the  fissure  had  been  cured  by  operation. 


1/2  CAUSES  OF  C  SORE  A. 

Dr.  Stevens^  of  New  York,  has  recently  attempted  to 
show  that  chorea  is  emphatically  a  nervous  disorder 
depending  upon  ocular  conditions.  He  has  found  that 
the  majority  of  cases  of  chorea  occur  among  hyper- 
metropic children  who  are  attending  school,  and  that 
the  widely  dilated  pupils^  which  constitute  a  very 
characteristic  feature  of  chorea,  become  normal  when 
the  complaint  passes  away.  When  hyper-metropic 
children  are  put  to  any  "^work  where  a  very  marked 
and  continued  effort  to  maintain  accommodation  is  re- 
quired_,  the  ciliary  muscle  experiences  fatigue^  and  finally 
exhaustion,  its  action  is  considerably  enfeebled,  and 
with  it  the  action  of  the  sphincter  pupillae.  The  widely 
dilated  pupil  is  the  signal  which  tired  nature  gives  as  a 
warning  to  discontinue  over-work  of  the  exhausted 
muscles.  If  the  signal  passes  unheeded  the  whole 
nervous  system  surrenders.^'  Dr.  Stevens'  experience 
leads  him  to  believe  that  cases  which  occur  without  any 
relation  to  ocular  troubles  are  rare  exceptions  to  a  very 
general  rule.  In  ii8  cases  of  chorea  occurring  in 
private  practice  simple  hyper-metropia  existed  in  78, 
and  astigmatism  with  other  complications  in  nearly  all 
the  remaining  cases.  I  have  seen  several  patients  in 
whom  the  chorea  depended  upon  ocular  abnormalities 
of  these  kinds. 


CHOBEA  AND  RHEUMATISM. 


The  connection  between  acute  rheumatism  and  chorea 
is  one  of  the  most  interesting  features  of  the  latter 
complaint.  Some  writers,  indeed,  go  so  far  as  to 
declare  that  chorea  is  always  of  rheumatic  origin,  while 
others  assert  that  rheumatism,  heart  disease,  and  chorea 
are  only  different  phases  of  one  and  the  same  disease, 
and  that  these  affections  may  occur  in  any  order  of 
sequence.  Chorea  is  often  preceded  by  an  attack  of 
acute  rheumatism  or  by  less  severe  pains  of  a  rheumatic 
character;  and  the  connection  is  still  further  evidenced  . 
by  the  fact  that  a  history  of  rheumatism  can  sometimes 
be  traced  in  the  parents  of  choreic  children.  It  is, 
however,  going  too  far  to  say  that  rheumatism  in  any 
form  is  a  necessary  precursor  of  chorea. 

Very  widely  differeat  views  are  held  as  to  the  nature 
of  chorea,  but  within  the  last  few  years  considerable 
light  has  been  thrown  upon  the  pathology  of  at  least 
some  of  its  forms.  More  or  less  serious  lesions  can  be 
found  in  fatal  cases,  especially  when  the  complaint  has 
been  preceded  by  rheumatism ;  the  difficulty  is  to 
account  for  mild  cases  which  rapidly  recover  under  the 
influence  of  good  food  and  fresh  air.  There  is  apparentlv 
much  truth  in  Dr.  Broadbent's  view  that  chorea  is  a 
symptom  rather  than  a  disease,  and  that  the  charac- 
teristic movements  are  in  relation  with  the  seat  of  the 


174  PATHOLOGY  OF  CHOREA. 

morbid  change  rather  than  with  its  nature.  "  The  seat 
of  the  disturbance  is  the  corpus  striatum^  its  character 
probably  different  in  different  cases ;  bat  the  anatomical 
condition  cannot  amount  to  actual  breach  of  structure, 
since  that  is  known  to  give  rise  to  hemiplegia,  while  it 
must  obviously  be  of  a  kind  to  impair  the  functional 
vigour  of  the  ganglia/^ 

Nearly  forty  years  ago  the  late  Dr.  Kirkes  reported  a 
series  of  cases  of  fatal  chorea,  in  which  on  post-mortem 
examination  inflammatory  changes  were  found  in  the 
cardiac  valves.  In  a  large  proportion  of  these  patients 
there  was  no  history  of  rheumatism,  and  in  a  few  of 
them  no  cardiac  murmurs  had  been  audible  during  life. 
Dr.  Kirkes  advanced  the  view  that  the  disorder  of  the 
nervous  centres  in  chorea  is  due  to  the  action  of  the 
inflammatory  products  of  the  endocardium. 

In  this  way  the  embolic  theory  of  chorea  originated, 
and  it  has  now  gained  pretty  general  acceptance.  In 
several  recorded  cases  vegetations  on  the  mitral  valve 
were  associated  with  embolisms  in  the  corpus  striatum 
and  thalamus  opticus.  Various  other  lesions  have 
been  found  ;  the  most  important  of  these  are  interstitial 
development  of  connective  tissue  in  the  nervous  centres  ; 
hyperemia  of  the  brain  and  spinal  cord  ;  serous  effusion 
and  extravasation  of  blood  in  the  spinal  canal.     Accord- 


PATHOLOGY  OF  CEOREA.  175 

ing  to  another  view  of  the  pathology  of  chorea,  the 
morbid  processes  are  of  a  diffused  character^  and  not 
confined  to  any  special  part  or  parts  of  the  nervous 
centres. 

The  alterations  found  in  the  spinal  cord  and  even  in 
the  peripheral  nerves  in  some  cases  are  held  to  support 
this  theory.  Dr.  Dickinson  examined  a  number  of 
cases  and  found  many  small  arteries  of  the  brain  and 
cord  much  dilated_,  the  change  being  especially  marked 
in  the  optic  thalamus  and  corpus  striatum.  Minute 
extravasations  were  also  visible_,  but  emboli  were  not 
detected. 

Dr.  Hughlings  Jackson  supports  the  embolic  theory; 
on  the  other  hand  Dr.  Striimpell^  of  Leipsic^  states  that 
this  theory  is  destitute  of  proof,  and  is  even  improbable. 
He  regards  chorea  as  a  ^'  neurosis,"  that  is_,  a  disease 
which  produces  functional  disturbances  for  which  an 
anatomical  basis  is  at  present  unknown. 

The  account  just  given  of  the  changes  found  in  fatal 
cases  of  chorea^  and  of  the  theories  as  to  the  nature  of 
the  disease,  will  suffice  to  show  the  uncertainty  which 
exists  on  this  latter  subject.  It  is  evident  that  very 
different  causes  must  be  at  work  in  severe  as  compared 
with  mild  cases. 


r76  SYMPTOMS  OF  CHOREA. 


Irritative  processes  and  capillary  embolisms  may 
account  for  the  former  class  ;  for  the  latter  some  other 
explanation  must  be  found.  The  rapid  subsidence  of 
the  convulsive  movements  would  seem  to  be  in- 
compatible with  the  presence  of  organic  lesions.  At 
present  it  seems  impossible  to  do  more  than  assume 
the  existence  of  nutritive  disorder  in  the  brain.  Such 
disturbance  may  depend  upon  hyperaemia,  with  stagna- 
tion of  blood  in  the  capillaries,  or  with  a  form  of 
thrombosis,  due  to  accumulation  of  masses  of  white 
corpuscles.  When  chorea  follows  directly  upon  shock 
vaso-motor  disturbance  may  be  presumed  to  exist,  with 
contraction  followed  by  dilatation  of  vessels  as  a  result. 
When,  lastly,  the  movements  seem  to  be  reflex  in 
character  (as  in  the  chorea  of  pregnancy),  it  must  be 
assumed  that  the  irritation  is  propagated  from  the 
peripheral  nerves  to  the  spinal  cord  and  brain.  Evidence 
in  support  of  the  view  that  chorea  is  essentially  a 
functional  disorder  will  be  found  in  the  introductory, 
chapter  of  this  work. 

Symptoms.  In  the  majority  of  cases  the  choreic 
movements  are  preceded  by  symptoms  indicative  of  dis- 
order of  the  general  health.  Fretfulness,  irritability, 
capriciousness,     indifference,     inattention,     etc.,      are 


SYMFTOMS  OF  CHOREA. 


177 


noticed  in  a  child  who  had  previously  exhibited 
none  of  these  traits.  The  appetite  fails,  the  sleep  is 
disturbed,  the  child  is  disinclined  for  exertion,  avoids 
his  companions,  and  seems  weak  and  ailing.  These 
symptoms  are  not  invariably  noticed,  thev  are,  of  course, 
absent  in  cases  of  chorea  supervening  on  fright,  or 
following  closely  an  attack  of  acute  rheumatism. 

After  these  symptoais  have  continued  perhaps  for 
some  weeks  the  choreic  movements  begin  to  be  noticed. 
There  is  first  a  general  restlessness  and  uneasiness  ; 
the  parents  are  apt  to  say  that  the  child  has  the 
"  fidgets ;  '^  he  moves  about  aimlessly,  and  seems 
awkward  and  clumsy  in  his  actions.  If  he  be  attending 
school  his  inattention  and  carelessness  are  complained 
of;  it  is  perhaps  noticed  that  his  handwriting  is  w^orse 
than  usual.  At  home  the  child  is  sometimes  punished 
for  carelessness  during  meals,  he  drops  things  from  his 
hand,  upsets  his  cup,  makes  grimaces,  and  seems  not  to 
heed  any  remonstrances.  At  this  stage  there  is 
generally  no  suspicion  as  to  the  real  nature  of  the  case. 
Before  long,  however,  definite  convulsive  movements 
occur. 

The  twitchings  usually  begin  in  the  hand  and  arm, 
and  thence  extend  to  the  shoulder^  face,  and  other  parts 


SYMPTOMS  OF  CHOREA. 


of  the  body.  In  most  cases  they  are  at  first  limited  to 
one  side^  the  left  being  more  frequently  affected  than  the 
right ;  but  sooner  or  later  the  affection  extends  to  the 
other  side  of  the  body.  The  twitchings  exhibit  every 
variety  of  force  and  character ;  the  fingers  are  often 
suddenly  flexed^  the  forearm  is  alternately  pronated  and 
supinated,  and  these  movements  are  combined  in  every 
possible  way^  so  that  the  limb  assumes  the  most 
unnatural  positions.  Many  muscles  of  the  neck  and 
face  are  similarly  affected_,  the  head  is  jerked  about,  and 
the  mouth,  nostrils,  and  eyebrows  are  contorted  in 
various  directions.  All  the  movements  are  exaggerated 
when  the  patient  knows  that  he  is  under  observation, 
and  especially  when  he  is  told  to  do  anything.  He  is 
able  to  perform  the  action,  but  he  does  it  hastily,  and 
executes  many  unnecessary  movements.  When  the 
twitchings  extend  to  the  leg  the  limb  is  moved  in 
various  directions  while  the  child  is  sitting  or  lying 
down.  When  he  walks  he  finds  that  he  has  imperfect 
control  over  the  limb  ;  it  becomes  difficult  for  him  to 
move  in  a  straight  line.  One  step  is  taken  rapidly,  and 
another  slowly,  and  the  steps  vary  in  length  and 
direction. 

In   the  early   stages  of  the    complaint  the  patients 
often  endeavour  to  disguise  the  convulsive  movements 


SYMPTOMS  OF  CHOREA.  i>jiy 

by  voluntarily  making  others  in  a  similar  direction. 
If,  however,  the  case  goes  from  bad  to  worse  voluntary 
movements  gradually  become  impossible  ;  the  patient 
can  do  nothing  for  himself,  but  has  to  be  dressed  and 
undressed,  fed,  and  otherwise  attended  to.  Continuous 
speaking  becomes  more  and  more  difficult,  and  at  last 
impossible ;  owing  to  inco-ordination  of  the  muscles 
of  the  lips  and  tongue  the  words  are  jerked  out  and  cut 
short.  There  is  often  some  amount  of  aphonia,,  due  to 
implication  of  the  muscles  of  the  larynx^  In  the  large 
majority  of  cases  the  movements  cease  during  sleep, 
which,  however,  is  often  restless  and  disturbed  by 
dreams. 

Evidences  of  mental  disorder  are  noticeable  in  many 
■cases  of  chorea.  The  irritability  and  excitement  which 
characterize  the  early  stages  are  apt  to  become  more 
and  more  decided ;  but  later  on  these  symptoms  are 
succeeded  by  others  indicative  of  depression  and  mental 
weakness.  The  face  wears  a  decidedly  fatuous  aspect, 
or  a  look  of  utter  despondency.  Studies  have  to  be 
given  up;  the  child  may  completely  forget  all  that  he 
had  previously  acquired,  and  appear  to  be  little  better 
than  an  idiot.  In  severe  cases  in  adults  the  patient 
may  become  maniacal. 

In   chorea,    as    in   many    other    nervous    affections, 


,8o  SYMPTOMS  OF  CJIOHJEA. 


there  are  great  differences  in  the  character  and  intensity 
of  the  symptoms  in  different  cases.  In  the  mildest 
forms  there  are  only  slight  twitchings  of  the  muscles  of 
the  face^  shrugging  of  the  shoulders^  or  perhaps  some 
irregular  movements  of  the  hands.  In  severe  cases  the 
convulsive  movements  may  extend  to  the  whole  of  the 
body,  and  be  so  violent  as  to  make  it  very  difficult  to 
keep  the  patient  in  bed.  Between  these  two  extremes 
there  are  many  various  degrees  of  severity. 

The  more  prominent  symptoms  require  a  somewhat 
closer  analysis.  The  motor  disorders  are  twofold,  and 
take  the  form  of  spontaneous  convulsions  and  subse- 
quently of  inco-ordinate  movements  which  result  from 
the  patient's  attempts  to  perform  common  actions. 
When,  for  instance,  he  wishes  to  hold  out  his  hand, 
the  limb  makes  a  series  of  movements  more  or  less 
wide  of  the  mark  before  the  purpose  is  accomplished. 
In  other  cases  common  voluntary  movements  are 
effected  in  a  manner  which  is  almost  normal,  whereas 
the  more  automatic  actions,  such  as  grasping  and  retain- 
ing an  object,  walking,  sewing,  writing,  etc.,  are  accom- 
panied by  marked  choreic  movements.  The  convulsive 
twitchings  do  not  seem  to  cause  fatigue,  but  as  time 
goes   on    a  general  weakness   becomes  developed,  and 


SYMPTOMS  OF  CHOREA.  i8i 

loss  of  power  iii  oae  side^  to  a  greater  or  less  extent,  is 
often  observed.  When  there  are  evidences  of  real 
paralysis  the  existence  of  organic  lesions  in  the  brain 
may,  of  course,  be  inferred.  The  galvanic  excitability 
is  generally  increased,  especially  on  the  affected  side  in 
cases  of  hemichorea. 

With  regard  to  disorders  of  sensation,  there  may  be 
some  amount  of  anaesthesia  in  one  or  more  limbs,  and 
pain  may  result  from  severe  spasms.  In  some  cases 
points  douloureux  can  be  detected  on  pressure  along  the 
spine,  and  on  the  large  nerve-trunks  of  the  extremities. 

Evidences  of  derano-ements  of  the  organs  of  circula- 
tion  are  often  present.  The  pulse  is  usually  frequent 
and  sometimes  irregular  owing  to  the  spasmodic  con- 
tractions of  the  muscles.  Murmurs  of  various  kinds 
are  audible  in  many  cases;  mitral  systolic  is  most 
common  in  those  connected  with  rheumatism;  in. 
anaemic  subjects  a  systolic  murmur  may  be  heard  at 
the  base,  gradually  to  disappear  as  recovery  proceeds. 

In  cases  of  chorea  of  average  severity  the  disorder 
lasts  from  six  weeks  to  three  months.  Its  course,  how- 
ever, is  seldom  uninterrupted ;  exacerbations  are  apt  to 
occur,  and  relapses  are  not  unfrequent  even  after  a 
recovery  supposed  to  be  complete.     Under  favourable 


i82  DIAGNOSIS  OF  CHOREA. 

circumstances  the  symptoms  gradually  subside;  the 
movements  of  the  legs  become  less  and  less  marked^ 
then  those  of  the  arms,  and  lastly  those  of  the  face.  In 
many  cases  contortions  of  the  features  are  noticed  for 
weeks  or  months  after  the  other  symptoms  have 
ceased.  In  children  the  prognosis  is  generally  favour- 
able^ complete  recovery  is  the  rule_,  and  sequelae  of  any 
kind  are  seldom  observed.  An  incurable  condition  of 
dementia  may_,  however,  supervene,  and  certain  muscles 
may  become  permanently  weak  and  atrophied. 

In  fatal  cases,  which,  unless  the  disorder  supervenes 
on  acute  rheumatism,  are  very  rare,  death  is  generally 
caused  by  exhaustion  due  to  the  severity  and  continu- 
ance of  the  paroxysms.  In  adults  the  disorder  always 
runs  a  very  chronic  course,  and  it  terminates  fatally  in 
a  large  proportion  of  the  cases.  About  30  per  cent,  of 
cases  of  chorea  occurring  in  pregnant  women  end  in 
death. 

Diagnosis.  In  the  majority  of  cases,  chorea  is  easily 
distinguished.  The  movements  may  be  mistaken  for 
those  which  characterize  disseminated  sclerosis,  but 
this  affection  occurs  mostly  in  adults  and  is  rare  in 
children. 

Moreover,  in  sclerosis  the  movements   consist  of  fine 


TREATMENT  OF  CHOREA.  183 

rhythmical  tremors  ;  in  chorea  they  are  much  more  ex- 
tensive^ and  of  a  jerky  character.  In  doubtful  cases 
the  course  of  the  disorder  under  treatment  will  aid  the 
diagnosis. 

Treatment.  Slight  cases  of  chorea  often  recover 
under  the  influence  of  good  food_,  a  proper  amount  of 
rest^  change  of  air  and  scene,  and  moderate  exercise^ 
and  these  and  all  other  measures  calculated  to  improve 
the  general  health  should  be  adopted  as  far  as  pos- 
sible. Every  endeavour  should  be  made  to  ascertain 
the  cause  of  the  attack,  or  the  circumstances  under 
which  it  originated. 

If  the  condition  be  one  of  anaemia  and  debility,  cod- 
liver  oil  and  iron  are  especially  indicated  ;  if  worms  be 
suspected,  suitable  anthelmintics  should  be  administered; 
and  any  existing  disorder  of  the  generative  organs  should 
be  carefully  inquired  into  and  treated.  Ordinary  routine 
treatment  should  not  be  adopted  until  a  thorough  ex- 
amination has  been  made  with  the  view  of  discovering  a 
local  source  of  irritation.  When  chorea  occurs  in  a  child 
attending  school  the  eyes  should  be  carefully  examined. 
If  hypermetropia,  asthenopia,  or  astigmatism  be  found 
to  exist  a  general  tonic  regimen  should  be  adopted,  and 
suitable  glasses  prescribed.     Absolute  rest  of  mind  must 


i84  TBEATMENT  OF  CHOREA. 

be  enjoined;  and  no  lessons  of  any  kind  are  to  be  thought 
of  until  the  choreic  symptoms  have  completely  disap- 
peared, and  a  decided  improvement  has  taken  place  in 
the  general  health.  In  cases  of  chorea  following  rheu- 
matism, iodide  of  potassium  with  alkalies  and  cinchona 
is  likely  to  be  serviceable,  and  cod-liver  oil  may  be  given 
at  the  same  time. 

When  all  possible  causes  have  been  dealt  with  as  far 
as  possible,  it  is  time  to  have  recourse  to  certain  drugs 
which  have  a  beneficial  action  on  the  symptoms. 
Arsenic  is  the  most  generally  efficacious,  and  Fowler's 
Solution  is  the  most  convenient  form  for  its  adminis- 
tration. From  three  to  ten  minims  may  be  given  in  a 
little  peppermint  water  or  infusion  of  orange  three  times 
a  day  after  meals.  It  is  well  to  begin  with  a  small  dose, 
and  gradually  to  increase  the  quantity  taken  by  adding 
one  minim  to  each  dose  every  four  or  five  days.  Sym- 
ptoms of  gastric  disorder  must,  of  course,  be  watched  for; 
if  the  appetite  fall  off,  if  there  be  pain  in  the  stomach 
or  frequent  eructations,  either  the  dose  must  be 
diminished  or  the  medicine  altogether  omitted  until  the 
gastric  symptoms  have  disappeared. 

Sulphate  of  zinc  is  another  remedy  of  this  kind,  but 
is  less  efficacious.     It  is  given  in  doses   of  a  grain   two 


TREATMENT  OF  CHOREA.  185 

or  three  times  a  day_,  and  these  are  gradually  increased 
by  successive  additions,  until  thirty  or  forty  grains  are 
taken  daily.  Strychnine,  as  recommended  by  Trousseau^ 
may  be  tried  if  arsenic  fails.  Iron  has  been  already 
mentioned  ;  it  may  be  combined  with  arsenic^  especially 
in  ^anaemic  cases. 

With  regard  to  external  remedies,  cold  applied  to  the 
spine  is  sometimes  very  efficacious  in  lessening  the  fre- 
quency and  extent  of  the  movements.  The  ether  spray 
or  an  ice-bag  may  be  employed.  The  latter  should  be  kept 
in  position  for  about  ten  minutes  daily,  or  the  spray  may 
be  applied  to  the  upper  part  of  the  spine  for  a  somewhat 
shorter  time. 

As  measures  of  a  tonic  character,  sponge  baths,  with 
tepid  or  cold  salt  water,  followed  by  friction,  are  useful 
auxiliaries.  Shower-baths  are  sometimes  recommended, 
but  are  seldom  advisable  on  account  of  the  alarm  they 
are  likely  to  cause. 

When  the  convulsive  movements  are  very  severe,  and 
so  continuous  as  to  deprive  the  patient  of  rest,  narcotic 
remedies  must  be  tried.  Chief  among  these  is  chloro- 
form, but  the  relief  it  affords  is  only  temporary.  Chloral 
hydrate  is  another  remedy  of  this  kind  ;  to  be  of  any  use 
it  must  be  given  in  full  doses.     Its   action  is  more  pro- 


1 86  TREATMENT  OF  CHOREA. 

longed  than  that  of  chloroform,  and  it  has  a  very  decided 
effect  upon  the  convulsive  movements.  While  the 
patient  is  under  its  influence  attempts  should  be  made 
to  administer  nourishing  food.  The  bromides  and  the 
preparations  of  opium  have  a  far  less  potent  influence  in 
arresting!;  the  movements. 

As  a  matter  of  course,  in  all  severe  cases  great  care 
should  be  taken  to  prevent  the  patient  from  injuring 
himself.  He  must  be  kept  in  bed  and  constantly 
watched. 

There  is  one  other  point  to  be  attended  to  in  connec- 
tion with  the  treatment  of  chorea.  In  view  of  the 
liability  of  the  disorder  to  spread  from  imitation,  the 
patient  should,  as  far  as  possible,  be  kept  away  from 
other  children. 


CHAPTER  Vir. 

NEURALGIA. 


Pain,  its  Nature — Sensory  and  Tactile  Nerves,  their  End- 
Organs,  Fibres,  and  Nerve-Centres — Varieties  of  Pain — 
Essential  Features  of  Neuralgia  —  Cause  of  Neuralgic 
Pain — Changes  in  Nerve-Centres — Atrophy  of  Posterior 
Roots — Vaso-motor  Disorder — Predisposing  Causes  of  Neu- 
ralgia, Hereditary  Predisposition,  Debility,  Age,  Sex — 
Exciting  Causes,  Cold  and  Damp,  Injuries,  Pressure  on 
Nerves,  Constitutional  Disorders,  Gout,  Diabetes,  Syphilis, 
and  Malarious  Fevers — Symptoms,  Peculiarities  and  Du- 
ration of  the  Pain,  Remissions,  Intermissions,  and  Re- 
currences— Locality  of  the  Pain  as  a  Guide  to  the  Cause — 
Pain  Extending  Centripetally  and  also  Radiating  Along 
the  Course  of  Neighbouring  'Nerves — Points  Douloureux — 
Cutaneous  HyperjEsthesia  and  Anesthesia — Motor  Disorder 
— Vaso-Motor  Disturbances  and  Disorders  of  Secretion  and 
Nutrition-t-Eruptions  of  Herpes  and  Erythema — Effects. 
OF  Neuralgia — Diagnosis — Treatment — Discovery  of  Cause 
— Symptomatic  Treatment — Quinine,  Arsenic,  Salicylate 
OF  Sodium,  Iodide  of  Potassium — Anodynes,  Morphine  and 
Atropine  —  Liniments  — Counter -Irritation  —  Electricity — 
Various  Tonic  Remedies — Neurotomy  and  Neurectomy — - 
Summary  of  Treatment. 


Pain  may  be  defined  as  a  peculiar  form  of  common 
sensation^  provoked  by  the  action  of  relatively  strong 
stimuli    on    sensorv    nerves.     According:  to   the   most 


i88  NJEURALGIA. 


recent  physiological  doctrines,  the  sensory  nerve  trunks 
contain  two  functionally  different  kinds  of  nerve  fibres, 
viz.,  those  which  convey  impressions  of  pain,  and  those 
which  administer  to  tactile  impressions;  with  the  latter 
group  the  sensations  of  temperature  and  pressure  are 
associated.  Landois  states  that  the  sensory  and  tactile 
nerves  have  in  all  probability  different  end-organs  and 
fibres,  and  that  they  have  also  special  perceptive  nerve- 
centres  in  the  brain,  although  this  is  not  definitely 
proved.  In  support  of  these  views  he  cites  among 
others  the  following  facts,  (i).  Tactile  sensations  are 
absent  from  all  internal  viscera ;  impressions  of  pain 
alone  are  discharged  from  these  organs.  (2).  The  con- 
duction channels  of  the  tactile  and  sensory  nerves  are 
in  different  parts  of  the  spinal  cord.  Tactile  impres- 
sions are  conveyed  through  the  posterior  columns  of 
the  same  side,  while  painful  impressions  are  conducted 
through  the  grey  matter,  and  some  of  the  conducting 
fibres  pass  from  one  side  of  the  cord  to  the  other.  (3). 
A  small  portion  of  the  grey  matter,  if  left  undivided, 
suffices  to  conduct  painful  impressions;  if  the  division 
be  complete  the  conduction  does  not  take  place,  but 
provided  that  the  posterior  columns  are  uninjured 
tactile    impressions    are    still    transmitted.     Thus    one 


CHAMACTEBISTICS  OF  NEURALGIA.  189 

sensation  may  be  abolished  while  the  other  is  retained. 
The  irradiation  of  painful  impressions,  so  often  noticed, 
is  explained  by  the  fact  that  they  are  conducted  by  the 
whole  of  the  grey  matter. 

Several  varieties  or  qualities  of  pain  are  more  or  less 
distinguishable  from  each  othery  and  are  often  described 
by  such  epithets  as  ''  burning/'  "  piercing/'  ''  cutting:/' 
"boring/'  "pricking/'  "splitting/'  "dull/'  "heavy/.' 
etc.  The  use  of  these  terms  implies  that  there  is 
something  superadded  to  the  peculiar  sensation  of  pain. 
Thus  when  the  hand  is  exposed  to  intense  heat  the 
sense  of  temperature  is  appealed  to,  and  a  definite 
quality  is  assigned  to  the  pain  ;  in  like  manner,  when  a 
needle  is  thrust  into  the  finger  the  sense  of  touch  is 
affected,  and  a  form  of  pain  distinguishable  from  other 
kinds  is  experienced. 

The  general  meaning  of  the  term  neuralgia  is 
sufficiently  obvious^  though  it  is  not  easy  to  suggest  a 
precise  definition.  Its  essential  features  may,  however, 
be  thus  described  :  — 

I.  Neuralgia  is  characterized  by  paroxysmal  attacks 
of  more  or  less  violent  pain,  coming  on  either  at  regular 
or  irregular  intervals  and  of  uncertain  duration,  and  pre- 
senting complete  intermissions  or  decided  remissions. 


igo  THEORIZES  OF  CAUSATION  OF  PAIN. 

2.  The  pain  extends  over  distinct  areas  supplied  by 
sensory  nerves^  and  is  likewise  felt  in  the  course  of  the 
nerve  trunks. 

3.  The  attacks  of  pain  come  on  spontaneously^  or  as 
a  result  of  slight  irritation. 

4.  There  is  no  discoverable  lesion  of  any  organ 
situated  within  the  region  which  is  the  seat  of  the  pain. 

5.  The  attacks  are  not  followed  by  any  general 
symptoms. 

The  various  ways  in  which  pain  may  be  provoked  are 
only  too  well  known^  but  the  actual  cause  of  neuralgic 
pain  is  still  a  matter  of  speculation.  According  to  a 
somewhat  plausible  theory  this  prominent  symptom  is 
due  to  a  chemical  process  or  change  acting  upon  the 
nervous  system.  Experiments  have  proved  that  irrita- 
tion of  a  nerve  is  followed  by  elevation  of  temperature 
in  the  nerve-substance,  and  a  change  in  its  chemical  re- 
action. Lactic  acid  and  acid  sodium  phosphate  are 
formed^  so  that  the  reaction  in  the  nerve- trunks, 
previously  alkaline,  becomes  at  least  neutral,  while 
in  the  nerve-centre  the  reaction  may  be  distinctly  acid. 
These  changes,  however,  are  only  of  a  temporary  charac- 
ter ;  the  acid  products  are  soon  neutralized  by  the  alkalies 
of  the  blood,  and  are  absorbed  and  removed.     Granted, 


THEORIES  OF  CAUSATION  OF  PAIN.  191 

however,  that  this  explanation  be  the  correct  one,  the 
manner  in  which  the  chemical  results  of  the  irritation 
act  upon  the  nerves  remains  unknown.  The  periodicity 
of  the  attacks  may  be  accounted  for  in  a  manner 
analogous  to  that  by  which  the  same  peculiaritv  of 
other  processes  is  explained.  The  inspiratory'act,  for 
example,  is  provoked  by  the  poverty  of  the  blood  in 
oxygen.  The  respiratory  centre  is  stimulated  when  the 
blood  has  lost  a  certain  amount  of  this  gas,  and  con- 
tains an  increased  amount  of  carbonic  acid.  In 
neuralgia  the  attacks  are  excited  when  sufficient 
quantities  of  the  irritating  materials  have  become 
accumulated.  At  first  and  for  some  time  neutrali- 
zation is  effected  as  above  described,  and  the  attacks 
cease ;  but  after  a  while,  as  a  result  of  fatigue  of  the 
vaso-motor  apparatus,  neutralization  and  absorption  are 
less  rapidly  effected,  and  the  attacks  increase  in  dura- 
tion and  severity.  After  a  time  central  changes  take 
place,  and  these  have  a  tendency  to  become  permanent. 
It  is  these  chano-es  in  the  nervous  centres  which  are 
concerned  in  the  production  of  the  pain.  In  neuralgia 
of  a  mixed  nerve,  if  onlv  the  trunk  were  affected,  motor 
phenomena  would  show  themselves,  but  this  com- 
plication is  not  always   observed.     The  irradiation   of 


192  TEEORIJES  OF  CAUSATION  OF  PAIN. 

the  pain  along  branches  of  other  nerves  is  likewise  a 
proof  of  the  existence  of  central  changes. 

This  theory  of  the  causation  of  pain  has  much  to 
recommend  it^  but  it  has  not  as  yet  been  supported 
either  by  experimental  or  pathological  evidence.  In  one 
case  of  tic  douloureux  recorded  by  Billroth  atrophy  of 
the  nucleus  of  the  fifth  nerve  was  found  combined  with 
dilatation  of  the  vessels. 

Other  theories  of  neuralgic  pain  deserve  a  brief 
notice.  The  late  Dr.  Anstie  considered  that  neuralgia 
was  due  to  atrophy,  or  to  processes  leading  to  atrophy, 
of  the  posterior  roots  of  the  spinal  nerves  or  of  the  grey 
substance  connected  with  them.  He  supposed  that 
certain  cells  and  groups  of  fibres  were,  so  to  speak, 
congenitally  loci  m'moris  resistentice,  under  the  in- 
fluence of  such  agents  as  exposure  to  cold,  injuries, 
mental  shocks,  alcoholic  excesses,  as  likewise  during 
puberty,  pregnancy,  and  senile  disordersof  nutrition.  It  is 
supposed  that  these  and  similar  causes  tend  still  further 
to  damage  cells  and  fibres  originally  weak,  and  ultimatelv 
produce  a  condition  of  atrophy.  Very  little  pathological 
evidence  has,  however,  been  adduced  in  support  of  this 
theory  ;  on  the  other  hand,  in  some  cases  of  neuralgia 
of  spinal  origin  the  roots  of  the  nerves  and  the  grey 


THEORIES  OF  CAUSATION  OF  PAIN.  193 


substance  of  the  cord  were  found  quite  normal,  whereas 
the  posterior  columns  showed,  very  decided  appearances 
of  irritative  changes.  The  fact  that  neuralgic  svmptoms 
are  common  in  the  earlv  stages  of  locomotor  ataxy 
would  appear  to  indicate  that  in  addition  to  the  roots 
and  the  grev  substance  the  posterior  columns  may  be 
implicated  in  the  causation  of  neuralgic  pains. 

According  to  another  view_,  atrophy  of  the  nerves^  due 
to  inflammatory  processes,  renders  them  liable  to  violent 
attacks  of  pain_,  the  original  seat  of  the  lesion  in  the 
majority  of  neuralgias  being  within  the  vertebral  canal  or 
in  the  cranium.  Inflammatory  affections  of  the  mem- 
branes of  the  cord  and  brain,  slight  in  extent  and  otherwise 
dev^oid  of  symptoms,  are  the  principal  lesions  of  this  char- 
acter. In  the  origination  of  these  excentric  neuralgiae_,  the 
vaso-motor  nerves  play  a  prominent  part,  inasmuch  as 
they  supply  the  mechanism  which  produces  an  attack  of 
pain_,  even  in  central  aflections.  Local  disorder  of 
circulation  at  the  seat  of  pain  is  the  result  of  the  action 
of  these  nerves.  The  same  vaso-motor  mechanism  can 
likewise  be  called  into  action  at  the  periphery  by  causes 
acting  there,  with  results  similar  to  those  due  to  central 
changes.  Primary  irritation  of  the  posterior  roots,  caused 
by  local  anaemia,  hypersemia,  etc.,  may,  bv  reflex  action 

13 


194  CAUSES  OF  NEURALGIA. 

upon  the  vaso-motor  fibres,  which  accompany  the 
anterior  roots,  play  a  conspicuous  part  in  the  produc- 
tion of  excentric  neuralgia. 

Without  discussing  these  theories  any  further  it  is 
sufficient  to  remark  that  vaso-motor  changes  would 
seem  to  furnish  a  clue  to  many  of  the  symptoms  of 
neuralgia. 

The  predisposing  and  exciting  causes  of  neuralgia  are 
of  various  kinds.  The  first-named  class  includes  (i) 
a  nervous  constitution,  for  the  most  part  of  hereditary 
origin  ;  {%)  debility  ;  (3)  age,  and  (4)  sex.  Neuralgia 
is  especially  liable  to  occur  in  persons  who  suffer  from 
other  nervous  affections  and  in  those  with  a  family 
history  of  such  disorders  as  epilepsy,  hysteria,  etc.  It 
is  also  common  in  anaemic  and  debilitated  subjects 
generally,  and  especially  in  those  whose  strength  has 
been  reduced  by  over-exertion,  bodily  or  mental,  excesses 
of  all  kinds,  etc.  Neuralgia  is  an  affection  of  adult 
life ;  but  it  sometimes  occurs  in  old  age,  though  rarely 
in  children.  Some  forms,  notably  tic  douloureux,  are 
more  common  in  women ;  others,  such  as  sciatica,  are 
more  frequent  in  men. 

Among  the  exciting  causes  of  neuralgia  cold  and 
damp  and  exposure  to  draughts  occupy  the  first  place. 


CA  USUS  OF  NE  URAL  GIA .  1 95 

We  have  no  certain  knowledge  as  to  the  manner  in 
which  cold  acts  upon  a  nerve_,  but  it  is  generally  sup- 
posed that  slight  anatomical  changes  of  an  inflammatory 
character  are  induced.  Other  causes  of  neuralofia  are 
injuries  of  various  kinds^  the  presence  of  foreign  bodies 
and  morbid  growths  in  the  neighbourhood  of  the  nerves  ; 
and  diseases  of  the  bones  and  periosteum,  especially  of 
that  lining  canals  through  which  the  nerve  passes. 
Pressure  upon  nerves,  however,  does  not  aKvays  give 
rise  to  neuralgia.  Various  constitutional  disorders,  e.g., 
gout,  diabetes,  syphilis,  and  malarious  fevers,  often  play 
an  important  part  in  the  production  of  neuralgia.  The 
influence  of  malaria  in  this  respect  is  often  well-marked, 
the  attacks  coming  on  at  regular  intervals,  and  curable 
only  by  large  doses  of  quinine. 

We  are  quite  in  the  dark  as  to  the  manner  in  which 
the  malarious  poison  affects  the  nerves.  Climatic  con- 
ditions, e.g.,  rapid  changes  of  temperature,  with  excess 
of  moisture  in  the  air,  determine  the  prevalence  of  neu- 
ralgia in  many  parts  of  the  world.  Neuralgic  pains 
occurring  in  gouty  subjects  may  be  attributed  to  the 
direct  influence  of  the  uric  acid  upon  the  nervous  tissue, 
but  why  certain  nerv^es  are  usually  affected  while  others 
escape  is   a  mystery  which    appears    to  defy  solution 


,()6  SYMPTOMS  OF  NEUEALGIA. 

In  some  patients  of  gouty  habit  the  pain  is  felt  in  the 
course  of  those  nerves  \vhich_,  from  their  position,  are 
most  exposed  to  the  influence  of  cold  and  damp. 
Analogous  to  these  cases  of  constitutional  neuralgia 
are  those  in  which  the  symptom  is  traceable  to  the 
presence  of  lead,  copper,  or  mercury  in  the  system. 
Some  forms  of  neuralgia  are  evidently  of  reflex  origin ; 
thus  diseases  of  the  uterus  often  excite  neuralgic  pains 
in  the  lower  limbs,  and  even  in  the  face  and  head. 

Symptows.  Neuralgic  pains  may  be  classified  under 
two  heads  ;  when  due  to  obvious  causes  they  are  known 
as  symptomatic ;  when  no  cause  can  be  ascertained 
the  term  essential  is  used.  As  instances  of  sym- 
ptomatic neuralgia  may  be  mentioned  the  severe  shoot- 
ing pains  characteristic  of  vertebral  caries,  and  of 
aneurisms  in  general ;  in  these  cases  the  pain  is 
assumed  to  be  due  to  inflammation  or  pressure.  In 
essential  neuralgia  no  such  causes  are  discoverable, 
and  we  are  too  ready  to  assume  that  they  do  not  exist. 
On  the  other  hand,  analogy  would  lead  to  the  inference 
that  severe  and  continuous  pain  is  always  connected 
with  changes  either  in  the  nerves  or  nerve-centres,  and 
the  term  essential,  as  applied  to  neuralgia,  should  be 
only  provisionally   used.     Subject    to    this    proviso,    a 


SYMPTOMS  OF  NEURALaiA.  197 

description  will  first  be  given  of  the  general  symptoms 
of  neural o;ia,  and  the  various  local  affections  of  this 
character  will  next  be  discussed. 

Neuralgic  attacks  are  most  frequently  preceded  by 
symptoms  indicative  of  irritation  of  the  cutaneous 
sensory  nerves  supplied  to  the  part.  These  prodromal 
symptoms  take  various  forms^  e.g.^  sensations  of  itch- 
ing, tingling,  cold_,  warmth_,  pressure,  tension,  etc. 
After  these  have  lasted  a  variable  time  pain  supervenes 
and  rapidly  increases  till  the  maximum  intensity  is 
reached.  In  some  cases  of  neuralgia  prodromal  sym- 
ptoms are  almost  or  altogether  absent;  the  attacks  come 
on  without  anv  w^arninsf.  A  common  feature  of  neu- 
ralgic  pain  is  the  lightning-like  rapidity  with  which  it 
shoots  through  the  affected  part;  it  starts,  as  it  were, 
from  a  centre,  and  radiates  in  various  directions  to 
certain  points  from  which  it  appears  to  return  to  its  seat 
of  origin.  At  the  height  of  its  intensity  it  is  often 
described  as  well  nigh  unbearable  ;  its  special  peculiari- 
ties are  further  designated  by  such  epithets  as  ''  prick- 
ing," ''' tearing,^^  ''Mourning,"  '^^  boring,"  and  similar 
terms.  The  duration  of  the  pain  varies  ;  in  many  cases 
after  remaining  at  the  same  degree  of  intensity  for  a  few 
seconds  or  minutes  a  remission  occurs,  or  even  a  com- 


198  SYMPTOMS  OF  NJEURALGIA. 

plete  intermission.  This  interval  again  varies  in  dura- 
tion ;  it  may  last  only  a  few  seconds^  when  the  pain 
recurs  with  its  former  intensity.  In  another  class  of 
cases  the  pain  continues  for  hours  or  even  for  several 
days,  with  temporary  remissions.  Even  when  very 
severe,  and  apparently  at  its  height,  lightning-like 
shocks  of  still  greater  intensity  are  often  experienced. 
Recurrences  are  wont  to  occur  either  at  regular  or 
irregular  intervals ;  and  between  the  attacks  the  patient 
is  either  quite  free  from  pain  or  complains  only  of  a 
feeling  of  soreness  or  bruising,  which,  though  it  may 
be  severe,  is  lightly  regarded  when  compared  with  the 
previous  agony. 

The  locality  of  the  neuralgic  pain  may,  to  some  extent 
at  least,  be  a  guide  to  its  origin.  Thus  gouty  neuralgia 
most  frequently  appears  in  the  form  of  hemicrania;  and 
other  forms,  notably  sciatica  and  facial  neuralgia,  some- 
times alternate  with  articular  gout.  Mr.  Hutchinson 
thinks  that  a  gouty  origin  may  be  assigned  to  neuralgic 
attacks  taking  the  form  of  sharp  explosions  of  lightning- 
like pains  over  the  parietal  bones,  and  occurring  in  quick 
succession,  but  unaccompanied  by  tenderness  on  pressure. 
As  I  have  stated  in  my  work  on  Gout,  "  such  attacks  are 
sometimes  to  be  traced  to  indulgence  in  wine  and  animal 


SYMPTOMS  OF  NEURALGIA.  199 

food  j  they  are  relieved  by  purgatives  and  alkalies.  We 
may  assume  that  the  pain  is  due  to  hyperaemia  and 
oedema  of  the  neurilemma,,  but  why  only  certain  branches 
of  a  nerve  should  be  affected  as  a  result  of  the  constitu- 
tional disorder  is  a  question  that  cannot  be  solved/' 
Neuralgia  due  to  syphilis  may  affect  almost  any  sensory 
nerve ;  in  the  early  part  of  the  secondary  stage  pain  in 
the  scalp^  from  the  ears  to  the  vertex^  and  extending  over 
a  space  two  inches  in  widths  is  comparatively  frequent. 
Facial  and  occipital  neuralgia  and  sciatica  are  also 
common  in  the  secondary  stage^  and  severe  intercostal 
neuralgia  has  been  noticed  in  a  few  cases. 

In  neuralgia  it  frequently  happens  that  the  pain  is 
felt  not  only  in  the  parts  supplied  by  the  peripheral 
expansion  of  the  nerve,  but  in  the  nerve-trunk  itself. 
Thus  in  neuralgia  of  the  fifth  pair  the  pain  often  shoots 
along  the  course  of  the  affected  branch,  usually  in  a 
centrifugal  direction  though  sometimes  towards  the 
nerve-centres.  In  the  latter  case  there  is  generally 
some  tenderness  on  pressure  over  the  course  of  the 
nerve,  a  symptom  which  may  be  regarded  as  indica- 
tive of  neuritis.  The  sheaths  of  the  nerves  are  supplied 
with  special  nerve-fibres,  and  are  thus  endowed  with 
sensibility.     The  tenderness  is  probablv  due  to  irritation 


200  SYMPTOMS  OF  NEURALGIA. 

of  these  nerves,  which  are  the  channels  for  the  conduc- 
tion of  painful  impressions. 

Radiation  along  the  course  of  neighbouring  nerves  is 
sometimes  noticed  in  connection  with  neuralgic  attacks. 
Thus  in  facial  neuralgia  affecting  one  branch  of  the  fifth, 
pain  is  occasionally  felt  in  another  branch,  in  the  occipital 
or  cervical  nerves,  or  even  in  some  branch  of  the  brachial 
plexus.  In  other  cases  the  pain  affects  a  branch  of  the 
fifth  on  the  opposite  side  of  the  face.  In  like  manner 
in  intercostal  neuralgia  branches  of  the  brachial  plexus 
are  sometimes  affected  ;  abdominal  neuralgias  are  some- 
times complicated  by  pains  in  the  thigh,  while  other  vis- 
ceral neuralgias  are  frequently  associated  with  pain  in  the 
cutaneous  nerves,  either  of  the  superjacent  surface  or 
at  some  distance  from  the  affected  part.  Such  radiation 
is  especially  apt  to  occur  when  the  pain  is  at  its  height, 
and  is  explainable  by  the  fact,  already  referred  to,  that 
the  whole  of  the  grey  matter  of  the  spinal  cord  serves 
for  the  conduction  of  painful  impressions,  the  effect  of 
which  is  in  proportion  to  their  intensity.  Radiated  pain 
of  this  character  may  be  described  as  reflex  neuralgia; 
examples  of  it  are  not  unfrequently  met  with  in  persons 
with  hereditary  predisposition  to  nervous  diseases. 

Certain    other    phenomena    are    often    prominently 


P OINTS  DOULO UR:E UX.  '  201 

associated  with  neuralgic  attacks ;  those  most  fre- 
quently noticed  are  the  so-called  points  douloureux,  the 
cutaneous  hyperaesthesia  and  hypaesthesia  and  symptoms 
of  vaso-motor  disorder.  Nearly  fifty  years  ago  atten- 
tion was  called  by  Valleix  to  the  fact  that  in  neuralgia 
affecting  superficial  nerves  it  is  often  possible  to  detect 
certain  spots  which  during  the  attack  are  exquisitely 
painful  on  pressure.  These  spots  are  always  to  be 
found  in  the  course  of  the  nerve-trunk_,  or  of  its  prin- 
cipal branches,  and  generally  correspond  with  bony 
foramina  and  openings  in  fibrous  structures  through 
which  nerves  pass.  The  area  of  tenderness  is  usually 
small  and  well  defined,  but  in  some  cases  a  large  por- 
tion of  the  trunk  of  the  affected  nerve  is  equally  sensi- 
tive to  pressure.  The  tenderness  is  most  marked  when 
the  pain  is  at  its  height,  and  is  either  reduced  to  a 
minimum  or  is  altogether  absent  during  the  intervals 
between  the  neuralgic  attacks.  These  points  douloureux 
are  not  discoverable  in  all  cases  of  neuralgia ;  it  is 
indeed  often  noticed  that  the  pain  is  relieved  by  firm 
pressure  over  the  nerve,  but  aggravated  by  a  gentle 
touch.  Spontaneous  pain  is  rarely  felt  at  these  points, 
even  during  a  severe  attack,  and  this  apparent  anomaly 
is   due  to   the  fact  that   the  integument  covering  the 


202  SYMPTOMS  OF  NEURALGIA. 


affected  nerve  is  often  supplied  by  nerves  unaffected  by 
the  cause  of  the  pain.  For  the  discovery  of  the  points 
douloureux  pressure  is  always  necessary.  It  has  been 
supposed  that  the  pain  thus  elicited  is  due  to  the 
existence  of  local  circumscribed  lesions,  of  an  inflam- 
matory character^  in  the  course  of  the  nerve,  such 
lesions  being  either  at  the  painful  spots  or  between 
them  and  the  nervous  centres. 

Some  amount  of  cutaneous  hyperaesthesia  is  a  frequent 
concomitant  of  neuralgia  and  especially  in  the  early 
stages;  as  time  goes  on  the  sensitiveness  of  the  skin 
is  apt  to  become  reduced,  though  not  to  any  great 
extent.  A  similar  change  is  sometimes  observable  in 
the  sensations  of  temperature,  pressure,  and  locality. 
The  anaesthesia  is  usually  restricted  to  the  part  supplied 
by  the  affected  nerve;  but  it  sometimes  extends  beyond 
this  limit.  Pain  of  a  non-neuralgic  character  is  oc- 
casionally followed  by  one  or  more  of  these  forms  of 
perverted  sensibility,  but  they  are  more  often  observed 
in  connection  with  neuralgia. 

Disorders  of  motor  nerves  are  not  unfrequently  as- 
sociated with  neuralgic  pain,  and  the  connection 
between  the  two  affections  may  be  either  direct  or 
reflex.     In  neuralgia  of  mixed  nerves   the   motor  fibres 


S  TMPTOMS  OF  NE  URA  L  GIA .  203 

are  liable  to  suffer  from  the  same  causes  which  act  upon 
the  sensory  nerves.  Hence  the  pain  may  be.  accom- 
panied by  symptoms  of  irritation^  such  as  fibrillary 
twitchings,  or  even  clonic  spasm  of  muscles_,  and  sub- 
sequently by  loss  of  power_,  seldom  amounting  to 
paralysis.  Symptoms  of  irritation  may  be  also  of  reflex 
origin  ;  thus  the  convulsive  form  is  sometimes  super- 
added to  tic  douloureux_,  and  this  is  due  to  reflex  irrita- 
tion of  the  facial  nerve_,  following  upon  the  irritation  of 
branches  of  the  fifth.  In  some  cases  of  neuralgia  the 
cardiac  and  respiratory  movements  are  aflTected  by  reflex 
action. 

Evidences  of  vaso-motor  disorder  are  commonly  ob- 
served in  various  forms  of  neuralgia.  Thus  at  the  be- 
ginning of  the  attack  there  is  usually  excitement^  and 
later  on  paralysis,  as  indicated  by  contraction  and  sub- 
sequent dilatation  of  the  blood-vessels.  In  many  attacks 
of  tic  douloureux  the  face^  conjunctiva  and  mucous 
membrane  of  the  nose  are  at  first  pale  and  afterwards 
flushed.  Even  the  gums  are  sometimes  aflected  in  a 
similar  manner.  In  sciatica  the  skin  of  the  leg^ 
especially  about  the  heel,  is  sometimes  observed  to  be 
reddened  when  the  pain  is  at  its  height. 

Evidences  of  disorders  of  secretion  and  uutrition  come 


204  SYMPTOMS  OF  NEURALGIA. 

next  in  point  of  frequency.  Daring  neuralgic  attacks  it 
is  often  noticed  that  the  saliva  is  increased,  that  the  tears 
and  nasal  mucus  flow  freely;  and  the  secretion  of  milk^ 
perspiration,  and  urine  has  been  observed  to  become 
more  abundant.  The  nutrition  of  the  affected  part  not 
imfrequently  suffers  in  chronic  cases^  the  changes  being 
most  prominent  in  the  hair_,  skin,  and  mucous  membrane. 
In  cases  of  supra-orbital  neuralgia  single  hairs,  or  even 
patches  of  hair,  sometimes  lose  their  colour  and  become 
white;  a  similar  change  has,  indeed,  been  observed  during 
an  attack,  the  hair  regaining  its  normal  colour  after  the 
pain  had  subsided.  •  Sometimes  the  hair  falls  out;  in 
rare  cases  it  grows  more  freely  and  becomes  thick  and 
coarse.  Changes  in  the  skin  itself  are  likewise  common; 
sometimes  there  is  copious  deposit  of  pigment,  more 
often  the  skin  and  subcutaneous  tissue  are  atrophied,  and 
the  muscles  are  apt  to  be  similarly  affected  in  cases  of 
neuralgia  of  the  limbs.  The  changes  in  the  mucous 
membranes  are,  of  course,  less  frequently  observed,  but  in 
neuralgia  of  the  fifth  pair  there  is  often  increased  growth 
of  the  epithelium  of  the  mouth,  and  especially  over  the 
tongue  on  the  affected  side. 

Other  forms  of  disorder  are  liable  to  appear  in  the 
integument,  the  most  marked  of  these  being  an  eruption 


SYMPTOMS  OF  NEURALGIA.  205 

of  herpes.  This,  in  some  cases,  is  very  peculiar ;  the 
course  of  the  affected  nerve  is  marked  out  by  a  red  streak 
upon  which  groups  of  small  vesicles  become  developed  ; 
these  contain  a  clear  watery  fluid,  which  afterwards 
becomes  cloudy  and  then  dries  up.  The  crusts  thus 
formed  drop  off,  leaving  reddened  patches,  but  some- 
times small  ulcers.  The  association,  however^  of  neu- 
ralgia with  herpes  is  by  no  means  constant;  for,  as  is 
well  known,  the  eruption  often  occurs  without  anv 
accompanying  pain  beyond  a  little  smarting.  When 
the  association  exists  the  pain  and  the  eruption  mav 
appear  together ;  but  more  frequently  the  latter  precedes 
the  former.  The  most  marked  form  of  herpes  is  seen 
in  connection  with  intercostal  neuralgia. 

Patches  of  erythema  and  even  erysipelas  are  some- 
times noticed  along  the  course  of  nerves  affected  with 
neuralgia,  and  the  redness  may  extend  for  some  distance 
on  either  side.  A  very  decided  attack  of  facial  erysipelas 
has  been  known  to  supervene  during  the  course  of  facial 
neuralgia,  the  attacks  of  which  ceased  to  trouble  the 
patient  after  the  erysipelas  had  subsided.  Pemphigus 
and  urticaria  are  less  frequent,  and  their  occurrence 
may  be  taken  as  evidences  of  neuritis.  The  condition 
known  as  ^'  glossy  skin  "  is  sometimes  witnessed  under 


2o6  DIAGNOSIS  OF  NEURALGIA. 


similar  circumstances.  The  skin  is  thin^  smooth^  shin- 
ing and  reddened^  and  looks  as  though  it  had  been 
stretched. 

Repeated  attacks  of  neuralgia  often  produce  a  very 
serious  effect  upon  the  general  health  of  the  patient  in 
consequence  of  the  severity  of  the  pain,  the  loss  of 
sleepj  and  of  appetite.  A  condition  of  profound  melan- 
cholia is  set  up  in  some  patients.  The  attacks  are  the 
more  trying  inasmuch  as  in  many  cases  there  is  no 
security  for  the  sufferers  that  they  will  be  free  from 
them  for  any  length  of  time  :  the  intervals  of  freedom 
are  for  the  most  part  irregular  and  uncertain,  and 
owing  to  the  depression  which  is  set  up  the  pain 
becomes  more  and  more  intolerable  as  time  goes  on. 
Its  severity  and  duration  are,  of  course,  influenced  by 
the  nature  of  its  cause  and  other  circumstances.  The 
younger  the  patient,  the  more  likely  is  the  pain  to  be 
relieved  or  cured  by  remedies ;  in  old  people,  especially 
if  debilitated,  neuralgia  is  generally  very  obstinate. 

Diagnosis.  The  diagnosis  of  neuralgia  is  for  the 
most  part  easy.  The  apparently  spontaneous  acces- 
sion of  the  pain,  its  intermittent  character,  its  cor- 
respondence with  the  course  of  certain  large  nerves, 
along  which   painful  spots  may   often  be  detected  on 


JDIA GNOSIS  OF  NE URA LGIA. 


pressure,  are  the  main  points  to  be  attended  to.  The 
cause  and  exact  seat  of  the  neuralgia  are  much  more 
difficult  to  determine.  It  is  important  to  decide 
whether  the  cause  be  peripheral  or  central.  In  the 
former  case  the  evidences  of  vaso-motor  disorder  and 
of  paralysis  (should  any  such  exist)  will  be  confined  to 
the  parts  adjoining  the  affected  nerve.  Neuralgia  of 
central  origin  is  inconstant  in  locality_,  apt  to  wander 
from  place  to  place_,  lancinating  in  character,  and  often 
appears  to  be  deeply  seated^,  whereas  in  the  peripheral 
form  the  pain  follows  the  course  of  a  more  or  less 
superficial  nerve.  Neuralgia  of  central  orio-in  is  a 
common  symptom  of  some  cerebral  and  spinal  dis- 
orders,  e.g.,  of  tumours  of  the  brain  and  of  locomotor 
ataxy. 

It  is  important  also  to  distinguish  cases  of  neuralgia 
due  to  neuritis  from  those  in  which  inflammation  of 
the  nerve  is  presumably  absent.  In  all  cases  complete 
intermission  of  pain  is  evidence  against  neuritis ; 
continuous  pains  (even  with  paroxysmal  exacerbations) 
are  in  favour  of  it_,  and  in  an  especial  degree  wdien 
associated  with  other  phenomena. 

The  presence  of  trophic  disorders  in  the  hair,  nails,  or 
skin  is  in  favour  of  neuritis,   and  so  likewise  is  early 


2o8  TBEATMIJNT  OF  NEURALaiA. 

anaesthesia,  appearing  in  the  course  of  a  few  days. 
Swellino;  of  the  affected  nerve  is  another  si2;n  of  inflam- 
mation,  but  it  does  not  occur  in  every  case^  and  is  often 
not  to  be  felt,  on  account  of  the  concealed  position  of 
the  nerve.  It  is,  moreover,  probable  that  the  appear- 
ance of  herpes  zoster  along  the  course  of  a  sensory  or 
mixed  nerve  is  evidence  of  neuritis,  generally  of  an 
acute  character.  In  cases  of  long-protracted  neuritis 
a  time  may  come  when  the  spontaneous  pain  and  the 
pain  elicited  on  pressure  may  both  disappear,  owing  to 
complete  destruction  of  the  nerve-fibres  resulting  from 
the  perineuritis  or  neuritic  processes. 

Treatment.  A  description  will  first  be  given  of  the 
treatment  of  neuralgia  in  general ;  the  remedies  more 
especially  suitable  for  the  various  forms  of  this  com- 
plaint will  be  mentioned  in  the  ensuing  chapters. 
Having  ascertained  that  any  given  case  is  one  of  true 
neuralgia,  every  attempt  should  be  made  to  ascertain 
whether  there  be  any  obvious  cause  of  the  pain,  i.e., 
whether  there  be  any  tumour  or  foreign  body  or  aneurism 
pressing  upon  or  irritating  the  nerve.  Inquiry  should 
also  be  made  for  evidences  of  constitutional  disorder, 
e.g.,  gout,  diabetes,  syphilis,  etc.  In  women,  evidences 
of  hysteria  should  be  sought  for  and   noted.     If  the 


TRJEATMJENT  OF  NEURALGIA. 


209 


attacks  recur  at  regular  intervals  inquiry  should  be 
made  as  to  whether  the  patient  has  ever  been  exposed 
to  malarious  influences,  and  a  similar  question  should 
be  put  with  regard  to  lead  and  mercurv  in  cases  in 
which  there  is  any  reason  to  suspect  the  influence  of 
these  metals. 

In  manv  cases  of  neuralgia  the  cause  remains  un- 
discovered even  after  the  most  careful  investigation, 
and  the  treatment  of  the  symptom  is  all  that  can  be 
attempted.  For  this  purpose  we  have  a  host  of 
remedies  at  our  disposal ;  some  of  these  will  now  be 
mentioned_,  but  their  special  uses  will  be  described  in 
the  chapter  on  the  various  forms  of  neuralgia.  Of  all 
medicines  quinine  is  the  one  most  generally  serviceable ; 
in  cases  due  to  malaria  it  often  acts  like  a  charm.  In 
other  cases  also  its  good  effects  are  often  no  less  re- 
markable. It  should  be  given  in  large  doses  (grains 
v-xx),  and  its  effects  watched.  EiBcacious  as  it  fre- 
quently is  in  tic,  it  is  seldom  of  any  avail  in  sciatica. 
If  there  be  headache  the  quinine  mav  be  advantageously 
combined  with  half- drachm  doses  of  dilute  hydrobromic 
acid.  Arsenic  may  be  tried  if  quinine  fails;  it  is  best 
given  in  the  form  of  Fowler''s  solution  (nj,  v-x)  three 
times  a  dav  after  meals.     If  there  be  an\    history  of 

14 


2 1 o  TRUA  TMjENT  of  NF  URAL  GIA . 

rheumatism  the  salicylate  of  sodium  may  be  tried  in 
doses  of  about  twenty  grains  every  four  or  six  hours. 
A  syphilitic  history  will  indicate  iodide  of  potassium, 
and  neuralgia  occurring  in  gouty  subjects  will  often 
yield  to  purgatives,  alkalies,  and  colchicum.  If  the  in- 
fluence of  lead  be  suspected,  iodide  of  potassium  and 
purgatives  should,  of  course,  be  tried. 

Anodynes  of  various  kinds  are  the  main  remedies  in 
the  symptomatic  treatment  of  neuralgia,  morphine  being 
the  one  most  commonly  used.     It  is  best  administered 
subcutaneously,    the   dose   being   proportioned   to    the 
severity  of  the  pain,  but  half  a  grain  of  the  acetate  should 
be  regarded  as  the  maximum.     It  is  not  necessary  to 
make  the  injection  close  to  the  painful  spot;  the  arm  or 
the    forearm    is    generally   the  most  convenient  place. 
Relief  is  almost  invariably   experienced,   and  in  some 
cases   the  pain  disappears  after  one  or  two  injections. 
Morphine  thus  administered  is  less  likely  to  affect  the 
head  and  organs  of  digestion  than  when  given  by  the 
mouth ;  but  patients  are  occasionally  met  with  who  can 
take  the  drug  in  the  latter   way    without   discomfort, 
whereas  a  hypodermic  injection  produces  most  distress- 
ing head- symptoms.     There  is  a  serious  drawback  con- 
nected with  the  use  of  morphine  in  severe  and  chronic 


TREA TMJENT  OF  NEURALGIA.  211 

caseSj  inasmuch  as  larger  and  larger  doses  are  required 
for  the  relief  of  the  pain ;  the  so-called  morphine-habit 
is  not  unfrequently  induced^  and  attended  with  conse- 
quences of  a  very  distressing  nature.  Under  no  circum- 
stances should  a  patient  be  allowed  to  inject  the  anodyne 
himself.  It  is  sometimes  advantageous  to  add  a  minute 
quantity  (gr.  i^o'tV)  of  the  sulphate  of  atropine  to  each 
dose  of  the  morphine  used  for  injection.  I  have  found 
this  combination  most  serviceable  ;  the  atropine  coun- 
teracts the  unpleasant  effects  of  the  morphine  on  the 
head  and  stomach.  For  external  application  anodynes 
may  be  used  in  a  great  variety  of  forms^  but  it  is  only 
slisrht  cases  of  neuralo;ia  that  are  thus  benefited.  The 
liniments  of  aconite,  belladonna,  and  opium,  either 
separately  or  combined,  may  be  thus  used,  and  a  little 
chloroform  liniment  may  be  added  with  advantage. 
These  and  other  anodynes  may  also  be  used  in  the  form 
of  ointment.  Aconitine  and  atropine  are  powerful 
remedies  thus  applied,  and  veratrine  does  good  in 
some  cases.  The  local  application  of  butyl-chloral  is 
sometimes  very  efficacious  in  facial  neuralgia. 

In  cases  in  which  there  are  evidences  of  neuritis,  that 
is  when  the  affected  parts,  and  especially  the  trunks  of 
the  nerves,  are  very  tender   on   pressure,  counter-irrita- 


212  TRIIATMJENT  OF  NEURALGIA. 

tion  is  often  serviceable.  For  comparatively  slight  cases 
we  may  employ  a  small  mustard  plaister,  or  the  com- 
pound liniment  of  mustard^  or  the  tincture  or  liniment 
of  iodine ;  but  these  remedies  are  better  adapted  to 
remove  the  soreness  and  aching  which  often  remain 
after  the  subsidence  of  the  acute  pain.  For  cutting 
short  an  attack,  if  neuritis  be  suspected,  it  is  better  to 
apply  blistering  liquid  along  the  course  of  the  nerve. 
When  the  pain  is  diffused,  and  affects  any  part  other 
than  the  face,  the  use  of  Corrigan's  firing  irons  is  often 
attended  with  the  most  satisfactory  results.  If  properly 
applied,  the  heated  iron  causes  no  pain.  In  some  cases 
of  neuralgia  it  is  sufficient  to  apply  counter-irritation  at 
some  distance  from  the  seat  of  the  pain ;  thus,  in  tic 
douloureux,  relief  is  sometimes  experienced  from  a  blister 
placed  behind  the  ear,  or  even  at  the  back  of  the 
neck. 

In  the  list  of  local  remedies  electricity  occupies  a 
prominent  place.  Its  application  often  relieves  the  pain 
in  a  marked  degree,  though  we  can  only  speculate  as  to 
the  manner  in  which  it  acts.  It  is  often  useful  in  cases 
in  which  it  exerts  no  influence  on  the  cause  of  the 
symptom,  and  in  essential  neuralgias  it  is  often  de- 
cidedly curative.     Opinions  differ  as  to  the  best  method 


TRJEATMENT  OF  NEURALGIA.  213 

of  applying  it,  and  if  it  be  wished  to  give  electricity  a 
thorough   trial  in  any  given  case  each  form  should  be 
tried  in   succession   if  others   fail.     In  all  cases  mild 
currents  should  be  first  tried^  and  the  strength  gradually 
increased  if  necessary.     The  good  effects  are  sometimes 
speedily  manifested.     In  other  cases  several  applications 
are  required,  while  in  a  third  class  no  relief  is  procured. 
It  is  hardly  possible  to  foretell  the  result  with  accuracy- 
in  any  case  of  neuralgia,  but  the  remedy  is  always  worth 
a  trial.     The  induced  current  is  applied  by  placing  one 
rheophore  in  the  patient^s    hand  or  on  any  convenient 
part  of  the  body^  and  drawing  the  other  over  the  course 
of  the  affected  nerve.     The  wire  brush  is  also  useful  for 
the  latter  purpose,  and  a  current  of  medium  strength 
should     be     used.      When    the    constant   or   galvanic 
current  is  selected,  the  anode  or  positive  pole  should  be 
placed  upon  the  affected  nerve  or  painful  spot  and  moved 
gently  over  it.  The  negative  pole  is  placed  in  the  patient^s 
hand,  and  the  strength  of  the  current  should  be  gradually 
raised.    Another  plan  is  to  keep  both  rheophores  in  close 
contact  with  the  skin  over  the  affected  nerve.     When  a 
long  nerve,  such  as  the  sciatic,  is  the  seat  of  pain,  the 
positive  pole  should  be  applied  over  the  spine  and  the 
negative  over  some  portion  of  the  course   of  the  nerve. 


214  TEJSATMENT  OF  NEURALGIA. 

It  may  either  be  kept  firmly  in  one  position  or  moved  to 
and  fro  over  the  seat  of  pain. 

Other  remedies  used  in  the  treatment  of  neuralgia  vi^ill 
be  mentioned  in  the  chapter  dealing  with  the  various 
forms  of  the  complaint.  It  v^ill  suffice  for  the  present 
to  enumerate  phosphorus  and  the  hypo-phosphites; 
iron^  which  is  almost  always  useful  in  anaemic  subjects  ; 
gelsemium  ;  the  bromides  ;  chloral^  etc. 

The  only  other  methods  of  dealing  with  neuralgia 
which  require  notice  are  of  a  surgical  character^  viz., 
diyision  of  the  affected  nerve  (neurotomy)  and  excision 
of  a  portion  (neurectomy).  Very  satisfactory  results 
are  sometimes  attained  by  these  means_,  but  they  should 
never  be  resorted  to  until  all  other  plans  have  failed. 
Neurotomy  is  most  successful  when  some  source  of 
irritation  which  cannot  be  removed  exists  at  the 
periphery,  but  it  has  been  known  to  succeed  in 
neuralgias  apparently  of  central  origin.  Neurotomy 
may  be  performed  subcutaneously,  but  there  is  this 
drawback  to  the  operation,  that  even  if  successful  at  the 
time,  the  nerve  is  apt  to  unite  and  the  pain  to  recur. 
Neurectomy  prevents  this  recurrence,  but  cannot,  of 
course,  be  performed  subcutaneously,  and  to  be  efficient 
may    involve    considerable   separation    of    the    parts. 


TBEATMJENT  bF  NEURALGIA.  215 

Nerve-Stretching  is  another  surgical  procedure  some- 
times successful.  It  is  impossible  to  explain  the 
manner  in  which  forcible  stretching  of  the  nerve  pro- 
duces its  good  effects,  but  it  has  been  suggested  that  in 
rheumatic  or  gouty  cases  the  operation  breaks  up  or 
overcomes  some  deposit  which  has  taken  place  in  the 
nerve  sheath. 

The  treatment  of  neuralgia  in  general  as  given  in  the 
preceding  paragraphs  may  be  thus  briefly  summarized. 
All  sources  of  irritation  should  be  carefully  searched  for 
and  dealt  with  according  to  circumstances,  and  every, 
endeavour  should  be  made  to  find  out  the  cause  of  the 
attack.  Relief  of  the  pain  is  the  next  indication,  and 
for  this  purpose  anodynes  are  geaerally  necessary. 
Electricity  should  then  be  tried,  and  likewise  such 
potent  remedies  as  quinine,  iron,  arsenic,  bromide  of 
potassium,  etc.  The  general  health  of  the  patient 
almost  invariably  requires  special  attention.  The 
surgical  operations  are  the  last  resource,  but  they 
must  not  be  regarded  as  altogether  desperate  remedies, 
inasmuch  as  they  have  proved  markedly  successful  in 
not  a  few  cases. 

Much  may  be  done  to  prevent  the  recurrence  of 
attacks,  especially  when  the  symptoms  have  been  com- 


2i6  TRIIATMENT  OF  NEURALGIA. 

paratively  mild.  Tonic  treatment  of  all  kinds  is 
generally  indicated.  Good  nutritious  food  taken  at 
proper  intervals,  removal  of  the  patient  from  an  un- 
healthy locality,  exercise  according  to  capacity^  warm  or 
cold  baths  are  all  likely  to  be  serviceable.  As  a  matter 
of  course,  the  patient  should  avoid  exposure  to  cold, 
over-exertion,  and  excesses  of  all  kinds. 


CHAPTER   VIII. 

VARIOUS  FORMS  OF  NEURALGIA. 


I.  NEURALGIA    OF    THE    TRIGEMINUS— TIC    DOULOUREUX. 
—II.  INTERCOSTAL  NEURALGIA.— III.    SCIATICA. 

I.  Causes  of  Tic    Docloureux — Symptoms — Pain — Duration    and 

Frequency  of  the  Attacks — Exciting  Causes — Two  Kinds 
OF  Pain — Motor  Disorder — Spasm  of  the  Facial  Muscles — 
Vaso-Motor  and  Trophic  Disturbances — Neuro-Paralytic 
Ophthalmia — Disorder  of  General  Health — Neuralgia  of 
the  Supra-Orbital  Branch — Neuralgia  of  the  Supra-  and, 
Inframaxillary  Divisions — Two  Stages  often  observed  in 
Facial  Neuralgia — Diagnosis  —  Treatment  —  Causal  and 
Constitutional — Electricity  —  Anodynes,  Morphine,  Gel- 
semium — Specific  Remedies,  Quinine,  Arsenic,  Iron,  Am- 
monium Chloride — Liniments  —  Counter  Irritation — Neu- 
rotomy— Neurectomy — Nerve-Stretching. 

II.  Intercostal  Neuralgia,  Causes    and    Symptoms — Points  Dou- 

loureux— Complications  and  Course — Diagnosis — Irritable 
Breast  or  Mastodynia — Symptoms  and  Differential  Diag- 
nosis— Treatment  of  Intercostal  Neuralgia  and  of  Mas- 
todynia. 
•III.  Sciatica,  its  Frequency  and  Causes — Symptoms,  their  Nature 
AND  Variety — Points  Douloureux — State  of  the  Muscles — 
Vaso-Motor  and  Trophic  Symptoms — Sugar  sometimes  found 
IN  THE  Urine — Electrical  Conditions  of  the  Affected 
Parts — Course  and  Duration  of  Sciatica — Diagnosis  — 
Prognosis — Treatment  —  Question  as  to  Causation  —  Rheu- 
matism—  Iodide  of  Potassium — Blisters  —  Hypodermic  In- 
jections of  Morphine  and  Atropine — Electricity — Flying 
Blisters — Acupuncture — Hot  Baths — Warm  Applications 
— The  Scotch  Douche — Hot  Sand-Baths — Massage — Nerve- 
Stretching. 


2i8  FACIAL  NEURALaiA. 

The  most  frequent  form  of  neuralgia  is  that  in  which 
the  fifth  pair  of  nerves  is  affected.  In  the  last  century 
the  complaint  was  described  by  Fothergill  as  "  painful 
affection  of  the  nerves  of  the  face."  All  three  divisions 
of  the  nerve  are  liable  to  be  affected ;  but  attacks  are 
more  common  in  the  ophthalmic  and  superior  maxillary 
than  in  the  inferior  maxillary  branch.  The  pain  is 
almost  always  unilateral.  The  comparative  frequency 
with  which  this  nerve  is  attacked  is  probably  due  to 
the  fact  that  its  branches  pass  through  bony  canals 
and  are  liable  to  irritation  or  compression  as  results 
of  periostitis_,  exostoses,  caries,  and  other  processes.. 
Peripheral  irritation  is  a  still  more  obvious  cause,  and 
marked  instances  of  this  character  are  those  in  which 
the  pain  is  due  to  a  carious  tooth  or  to  exposure  to 
cold.  Wounds  of  the  face  of  various  kinds  and  the 
lodgment  of  foreign  bodies  are  occasional  causes,  and 
they  may  act  either  upon  the  peripheral  expansion  of 
the  nerves  or  upon  small  branches.  Lesions  within 
the  cranium,  e.g.,  tumours  at  the  base  of  the  skull,  and 
aneurisms,  are  still  rarer  causes  of  neuralgia,  and  in  this 
category  may  likewise  be  included  diseases  of  the  nasal 
fossae,  frontal  sinuses,  and  of  the  tympanum.  The 
majority  of  the  above-mentioned  causes  are  of  an 
obvious    character^    but    there    are   many  cases    of  tic 


CAUSES  OF  FACIAL  NEURALGIA.  219 

douloureux  in  which  there  is  no  evidence  of  any 
anatomical  lesion.  Syphilis,  rheumatism,  and  gout 
may  be  mentioned  as  constitutional  causes;  and  like- 
wise anaemia  and  chlorosis  and  conditions  of  debility 
in  general..  The  possibility  of  syphilis  as  a  cause  of 
neuralgia  should  always  be  borne  in  mind.  I  have  lately 
been  consulted  by  a  gentleman,  aged  49,  a  martyr  to 
facial  and  general  neuralgia,  which  had  been  altogether 
uninfluenced  by  quinine  and  other  tonics.  On  inquiry  I 
discovered  that  the  patient  had  had  syphilis  thirty  years 
previously.  I  prescribed  the  iodides  and  small  doses  of 
mercury,  and  in  seventeen  days  the  patient  was  quite  free 
from  pain,  and  since  that  time  he  has  had  no  return 
of  the  symptoms.  Exposure  to  malarious  influences 
is  another  potent  cause,  and  in  a  few  cases  exces- 
sive use  of  the  eyes  has  been  followed  by  neuralgia  of 
the  fifth  nerve.  The  complaint  is  very  rare  in  children 
and  not  common  in  young  adults,  unless  in  connection 
with  carious  teeth ;  the  patients  are  generally  middle- 
aged  or  elderly,  and  females  are  more  often  attacked 
than  males.  It  should  never  be  forgotten  that  con- 
ditions and  disorders  of  organs  far  distant  from  the 
seat  of  pain  may  be  the  actual  cause  of  the  symptom. 
Thus  tic  douloureux  is  sometimes  associated  with 
obstinate  constipation,  and   ceases   at  once  when  the 


2 20  SYMPTOMS  OF  FA  CIA L  NE  URA LGIA. 

latter  condition  is  relieved.  There  are  other  instances 
of  a  similar  character^  e.g.,  those  in  which  the  pain 
occurs  in  persons  suffering  from  disorders  of  the  uterus, 
bladder_,  bowels,  etc.,  and  lasts  until  these  causes  have 
been  satisfactorily  dealt  with. 

Symptoms.  In  neuralgia  of  the  fifth  pair  the  pain  is 
of  a  more  severe  character  than  in  any  other  form.  Its 
outbreak  is  often  preceded  by  various  abnormal  sensa- 
tions, such  as  formication,  burning,  soreness,  tension, 
etc.,  and  sometimes  by  fibrillary  twitching.  The 
paroxysms  of  pain  are  liable  to  come  on  spontaneously ; 
but  speaking  and  eating  are  very  apt  to  provoke  them. 
In  severe  cases  the  patient  appears  to  be  struck  down 
by  the  pain ;  he  places  his  hand  against  his  face  and 
expresses  the  intensity  of  his  sufferings  by  gestures  and 
signs.  The  pain,  indeed,  according  to  the  subsequent 
statements  of  many  patients,  transcends  description; 
it  is  compared  to  that  caused  by  a  hot  iron^  a  knife,  a 
gimlet,  etc.  The  pain  is  liable  to  shoot  along  other 
nerves,  e.g.,  the  occipital,  and  sometimes  to  the 
shoulder  and  clavicle.  During  the  intervals  there  is 
usually  at  first  more  or  less  hypersesthesia,  but  after- 
wards anaesthesia  in  the  area  of  distribution  of  the 
affected  nerve.  An  eruption  of  herpes  sometimes  pre- 
cedes the  loss  of  sensation. 


SYMPTOMS  OF  FACIAL  NEURALGIA.  221 

The  attacks  vary  considerably  as  regards  their  dura- 
tion and  frequency.  The  acute  pain  may  last  for  a  few 
s'econds  or  for  several  minutes^  or  even  for  some  hours. 
When  thus  protracted^  the  intensity  of  the  pain  is  less 
than  in  the  shorter  attacks^  but  lightning-like  seizures 
of  great  severity  are  apt  to  occur  at  short  intervals.  In 
some  cases  many  attacks  occur  durins;;  the  twentv-four 
hours ;  in  others  the  pain  comes  on  daily  or  every  other 
day^  or  at  still  longer  and  irregular  intervals,  and  there 
are  innumerable  varieties  in  this  respect.  Most  patients 
can  recognize  two  kinds  of  pain :  the  one  continuous 
and  the  other  paroxysmal.  When  the  muscular  spasms 
come  on,  the  continuous  pain  ceases,  but  the  agony 
during  the  paroxysms  is  very  great.  Sometimes  the 
shocks  are  so  frequent  as  to  be  almost  continuous; 
they  are  only  momentarily  interrupted  by  exhaustion  of 
the  nerve.  The  most  trifling;  causes  suffice  to  induce 
attacks  in  some  patients,  such  as  speaking,  eating,  a 
touch  upon  the  face,  combing  the  hair,  changes  of 
temperature,  exposure  to  a  draught,  etc.  I  occasionally 
see  an  elderly  lady  who  has  been  afflicted  with  tic 
douloureux  for  many  years,  and  in  v/hom  a  paroxysm 
is  induced  when  she  is  suddenly  addressed.  In  another 
case  a  paroxysm  comes  on  when  the  eyes  are  exposed 
to  a  strong  light,  either   sunlight   or  artificial.     Very 


222  SYMPTOMS  OF  FACIAL  NFURALGIA. 

often  indeed  the  attacks  come  on  spontaneously,  i.e., 
without  obvious  causation.  In  some  patients  mental 
excitement  is  enough  to  cause  an  attack.  Unless  due 
to  syphilis,  the  pain  is  usually  less  troublesome  at  night. 
In  warm  summer  weather  the  patient  may  remain  free 
from  pain ;  the  attacks  are  generally  more  severe  and 
common  in  the  winter  and  in  damp  weather.  Even 
when  pain  is  absent  there  are  often  abnormal  sensa- 
tions in  the  area  of  distribution  of  the  affected  nerve. 

Symptoms  indicative  of  motor  disorder  are  often 
present  in  the  form  of  convulsive  spasms  of  the  muscles 
supplied  by  the  facial  nerve.  These  generally  precede 
the  attack,  increase  in  degree  and  extent  when  the  pain 
is  at  its  height,  and  subside  during  remission.  It  is 
sometimes  noticed  that  the  convulsions  do  not  occur 
until  the  pain  has  existed  for  several  days  or  weeks.  In 
severe  cases  the  muscular  movements  may  resemble 
those  of  convulsive  tic.  Sometimes  the  muscles  of 
visual  accommodation  are  similarly  affected,  and  spasms, 
both  tonic  and  clonic,  of  the  muscles  of  mastication 
(supplied  by  the  motor  branch  of  the  fifth)  are  occa- 
sionally observed.  These,  however,  are  far  less  common 
than  similar  affections  of  the  muscles  supplied  by  the 
facial  nerve,  and  this  fact  would  seem  to  indicate  that 
the  nuclei  of  origin  of  the  sensory  portion  of  the  fifth  are 


SYMPTOMS   OF  FACIAL  NEURALGIA.  223 

more  closely  connected  with  the  nuclei  of  the  facial  than 
with  those  of  the  motor  branch. 

Vaso -motor  disorder  shows  itself  by  redness  and 
swelling  of  the  affected  side  of  the  face  during  the 
attack;  the  eye  is  often  suffused,  and  the  gums  swollen. 
Tears  may  flow  down  the  cheek_,  and  the  salivary  and 
nasal  secretions  are  apt  to  be  increased  in  amount. 
These  latter  symptoms  may  remain  for  some  time  after 
the  pain  has  subsided.  Symptoms  indicative  of  trophic 
disorder  are  frequent  results  in  chronic  cases.  Some- 
times the  face  remains  swollen^  and  the  features  are 
enlarged  on  the  affected  side.  An  eruption  of  herpes  is 
a  frequent  complication  ;  a  streak  of  the  integument 
becomes  swollen  and  reddened_,  and  is  covered  with 
groups  of  tiny  vesicles.  A  similar  appearance  is  some- 
times seen  on  the  conjunctiva  covering  the  cornea_,  and 
the  result  of  such  an  eruption  may  be  permanent 
opacity  of  the  latter  structure,  and  even  destructive 
inflammation  has  been  known  to  supervene.  Another 
very  serious  lesion  of  this  character  is  the  so-called 
Jieuro-paralytic  ophihahnia,  which  takes  the  form  of  an 
ulcerative  keratitis  generally  in  the  lower  part  of  the 
cornea^  and  sometimes  leads  to  purulent  disintegration 
of  the  eyeball.  It  is  doubtful  whether  this  affection  is 
the  direct  result  of  disordered  nutrition.     It  seems  more 


224  SYMPTOMS  OF  FACIAL  NEUEALaiA. 

probable  that  it  is  due  to  mechanical  causes  and  irritants 
of  the  presence  of  which  the  patient  is  unconscious, 
owing  to  the  loss  of  sensibility.  It  may  be  that  the 
condition  of  the  nerve  lessens  the  capacity  of  the  part 
for  resisting  irritation.  Deafness  sometimes  occurs  in 
connection  with  facial  neuvalgia,  and  subsides  w^hen  the 
pain  is  relieved.  A  very  common  phenomenon  is  loss 
of  colour  of  the  hair,  especially  of  the  eyebrows.  In  the 
intervals  the  hair  that  grows  is  generally  normal  in 
colour,  but  sometimes  the  entire  hair  remains  perma- 
nently white  or  grey. 

The  general  health  always  suffers  in  cases  of  severe 
tic  douloureux.  The  pain  and  loss  of  sleep  are  apt 
to  cause  great  depression  of  spirits  and  irritability.  A 
condition  of  profound  melancholia  sometimes  sets  in, 
and  not  a  few  of  such  patients  seek  relief  from  morphine 
and  alcohol,  both  of  which,  but  particularly  the  latter, 
tend  eventually  to  aggravate  the  neuralgia,  besides  caus- 
ing their  own  deleterious  effects. 

Having  given  this  general  description  of  tic  doulou- 
reux, it  seems  desirable  to  indicate  the  peculiarities  of 
the  symptoms  connected  with  neuralgia  of  each  of  the 
three  divisions  of  the  nerve. 

The  supra-orbital  branch  of  the  ophthalmic  division 
is  the  one  most  frequently  attacked.  The  pain  sometimes 


SYMPTOMS  OF  FACIAL  NEURALGIA.  22; 

takes  theform  of  ciliary  neuralgia,  and  occurs  in  combina- 
tion with  such  symptoms  as  spasm  of  the  eyelids,  intole- 
rance of  light,  and  profuse  lachrymation.  Neuralgia  with 
these  symptoms  is  not  uncommon  in  scrofulous  children. 
Catarrh  of  the  frontal  sinuses  is  another  cause  of  neu- 
ralgia of  this  branch.  The  pain  is  probably  due  to  the 
pressure  of  the  accumulated  secretion  upon  the  nerves  dis- 
tributed to  t?he  membrane  lining  the  sinuses.  In  this  form 
the  pain  may  extend  from  the  eyelids  to  the  vertex,  down- 
wards to  the  tip  of  the  nose  and  laterally  to  the  temple. 
Pressure  over  the  supra- orbital  foramen  will  elicit  pain, 
and  other  points  douloureux  may  generally  be  detected 
,     on  the  side  of  the  nose  and  on  the  upper  eyelid. 

When  the  second  division  of  the  nerve  is  affected  the 
pain  is  usually  felt  in  the  infra-orbital  branch,  and 
pressure  over  the  foramen  of  the  same  name  causes 
severe  pain.  Other  points  douloureux  are  to  be  found 
over  the  malar  bone,  and  on  the  upper  lip,  and  the 
alveolar  process  of  the  superior  maxillary  bone.  In  old 
people  this  latter  part  is  sometimes  the  seat  of  verv 
severe  pain,  due  to  irritation  of  the  nerve  from  deposit 
of  bony  substance.  The  palatine  and  naso-palatine 
branches  are  seldom  the  seat  of  neuralgia. 

In  neuralgia  of  the  inferior  maxillary  nerve  the  pain 

15 


226  C0UR8:E  OF  FACIAL  NEURALGIA. 

is  usually  felt  in  the  inferior  dental  branchy  and  the 
internal  opening  of  the  inferior  dental  canal  and  the 
mental  foramen  are  the  ordiwdiVy  points  douloureux.  The 
auriculo-temporal  branch  is  less  commonly  affected. 
This  branch  supplies  the  meatus  auditorius  and  the 
articulation  of  the  jaw,  and  a  painful  point  may  be 
found  over  the  temporal  bone.  Only  in  very  rare 
instances  is  the  lingual  branch  the  seat  of  neuralgia. 
The  symptoms  are  acute  pain  or  a  sensation  of  pins 
and  needles  at  the  tip  of  the  tongue.  Salivation  is  a 
prominent  symptom  in  neuralgia  of  the  inferior  maxillary 
nerve.  In  such  cases  one  side  of  the  tongue  is  often 
thickly  coated,  and  there  may  be  irregular  movements 
of  the  muscles  of  mastication  and  also  of  the  tongue 
itself. 

It  rarely  happens  that  all  the  three  divisions  of  the 
nerve  are  simultaneously  affected,  but  whenever  this  is 
the  case  the  points  douloureux  are  to  be  found  in  a  line 
from  above  downwards,  viz.,  at  the  supra-orbital  notch, 
and  the  infra-orbital  and  mental  foramina. 

The  uncertain  course  which  neuralgia  takes  has  been 
already  alluded  toj  but  it  not  unfrequently  happens 
that  at  least  two  stages  can  be  recognized.  In  the 
first,  there  is  more  or  less  severe  continuous  pain  with 
frequent  exacerbations,  during  which  muscular  twitch- 


COURSE  OF  FACIAL  NEURALGIA,  227 

ings  come  on.     After  a  while  the  continuous  pain  sub- 
sides, but  the  severity  and  frequency  of  the  paroxysnis  ' 
remain   as    before.      Later    on,    however,    the    latter 
become  less  frequent,  and  are  no  longer  spontaneous, 
but  occur  only  as  the  result  of  movements,  or  of  bring- 
ing   something    into  contact  with  the   face.      In  the 
absence    of  these    causes   of   excitement   the   patient 
enjoys  immunity  from  pain,  and  shows  no  signs  of  the 
suffering  which  characterized  the  previous  period.     This 
phase  of  the  disorder  may  last  for  some  weeks,  and  pre- 
cede the  complete  cure;  its  supervention  shows  that 
the  hyperaesthesia  of  the  affected  nerves  is  so  slight  as 
to  be  insufficient  to  cause  spontaneous  pain.       It  still, 
however,  exists,  though  in  a  latent  condition,  and  rises 
to  such  a  degree  as  to  cause  pain  when  either  movement 
or  contact  with  a  foreign  body  sets  up  the  slightest 
amount  of  excitement.      Speaking  and  eating  are  both 
liable  to  cause  acute  suffering;   the  swallowing  of  fluids 
is  accomplished  with  less   pain,  but  the   contact  of  a 
glass,  cup,  etc.,  with  the  lips  is  almost  certain  to  pro- 
duce a  paroxysm.       As  time  goes  on,  it  is  found,  per- 
haps almost  suddenly,   that  paroxysms  are  no  longer 
provoked  as  above  described ;  perhaps  a  little  tingling  is 
all  that  remains,  but  this,  too,  disappears  in  the  course 
of  time. 


228         tm:eatment  of  facial  neubalgia. 


Diagnosis.     This  is  for  the  most  part  easily  made^  the 
distinguishing  points  being  [a)  the  paroxysmal  and  spon- 
taneous character  of  the  pain^  and  the  facility  with  which 
it  is  excited  by  slight  causes;   [h]  its  correspondence 
with  the  trunks  or  branches  of  large  nerves^  and  (c)  the 
existence  of  points  douloureux.       Pain  in  the  head  and 
face  may  likewise  be  due  to  inflammatory  affections  of 
the  bones  or  periosteum,  to.  inflammation  of  the  tem- 
poro-maxillary  articulation,    etc.,    but    such    cases    are 
easily,  distinguishable  from  those   of  neuralgia.      It  is 
important  to  determine  whether  the  cause  of  the  pain  is 
situated  within  or  outside  the  cranium.       As  a  general 
rule  implication  of  several  or  many  branches  of  the  nerve 
is  indicative  of  a  central  origin,  while  the   restriction   of 
the    pain   to   one   or  two  branches    points  rather  to  a 
peripheral  cause.     The  determination  of  the  cause,  how- 
ever, of  cases  in  which  several  branches  are  aflTected  may 
be   very  difficult ;  absolute  incurability  is,  perhaps,  the 
only  indubitable  sign  of  an  intracranial  cause.     Neuralgia 
affecting  simultaneously  all  three  divisions  of  the  nerve 
is  by  no  means  necessarily  of  central  origin. 

Treatment.  The  general  principles  of  the  treatment 
of  neuralgia  have  already  been  described  (see  page  208). 
Every  attempt  should  be  made  to  discover  the  cause. 
When  the  lower  part  of  the  face  is  the  seat  of  the  pain 


TREATMENT  OF  FACIAL  NEURALGIA,  229 

carious  teeth  will  often  be  found,  and  these  should  be 
removed  or  otherwise  dealt  with.  When  the  teeth  are 
not  carious^  and  painful  only  during  the  attacks,  it  is 
useless  to  remove  them.  When  there  is  a  history  of 
syphilis  or  of  exposure  to  malaria,  iodide  of  potassium 
and  quinine  are  respectively  indicated.  Affections  of 
the  tympanum  should  be  remembered  as  possible  causes 
of  facial  neural2:ia,  and  likewise  catarrh  of  the  frontal 
sinuses  in  cases  where  the  supra-orbital  branch  is  the 
seat  of  pain.  The  catarrh  may  be  relieved  by  a  nasal 
douche  of  tepid  water,  containing  gr.  v  of  Sod.  Bicarb, 
and  Ammon.  Chlorid.  to  5  j,  and  by  restoring  the  com- 
munication between  the  nose  and  the  frontal  sinuses, 
the  pressure  on  the  nerves  will  be  lessened,  aud  the  pain 
will  subside.  I  have  seen  many  cases  much  benefited 
by  these  measures. 

When  the  neuralgia  appears  to  be  connected  with 
constitutional  conditions,  such  as  various  forms  of 
debility,  the  preparations  of  quinine  and  iron  will  be  of 
marked  service.  When,  on  the  other  hand,  there  are 
symptoms  of  plethora  and  of  cerebral  hyperaemia,  saline 
purgatives  are  indicated,  and  may  be  given  in  the  form 
of  the  various  mineral  waters,  e.g..  Fried richshall^ 
Marienbad,  etc. 

For  the  direct  treatment  of  tic  douloureux,  we  have  at 


230  TBUA TMENT  OF  FA CIAL  NF URALaiA. 

our  command  electricity  in  various  forms,  and  certain 
anodynes  and  so-called  specific  remedies.  Surgical  aid 
may  also  be  sought  for  cases  otherwise  intractable. 

The  continuous  current  is  generally  to  be  preferred 
to  the  induced ;  its  application  is  more  efficacious, 
and  causes  less  pain.  The  negative  pole  should  be 
pressed  against  the  back  of  the  neck,  and  the  positive 
applied  to  the  various  painful  points  for  from  two  to  five 
minutes,  the  strength  of  the  current  being  gradually 
increased.  In  severe  cases  two  applications  may  be 
made  daily,  and  it  is  sometimes  of  advantage  to  apply 
the  current  to  the  sympathetic  in  the  neck.  The  effi- 
cacy of  galvanism  is  sometimes  very  marked  in  cases  of 
recent  origin,  and  sometimes  even  old-standing  cases, 
which  have  resisted  all  other  methods  of  treatment,  are 
relieved  or  cured  by  this  remedy.  If  it  fails,  the  induced 
current  may  be  tried.  A  well-moistened  sponge  elec- 
trode is  placed  on  a  painful  spot;,  and  the  other  at  the 
back  of  the  neck,  while  the  secondary  current  is 
gradually  brought  into  operation. 

Of  remedies  belonging  to  the  anodyne  class,  morphine 
is  the  most  useful,  and  is  best  administered  subcu- 
taneously.  Large  doses  are  often  required  to  produce 
any  effect  upon  the  pain.     The  butyl-chloral  is  another 


TREA  TMENT  OF  FA  CIA L  NF  URA L  GIA .  231 

valuable  remedy  ;  about  three  grains  should  be  given  in 
a  pill  with  mucilage  of  tragacanth  every  two  hours  up 
to  six  or  eight  doses_,  if  required.  Gelsemium  has  an 
almost  specific  action  in  some  cases  ;  it  is  given  in  the 
form  of  the  tincture  rrt  x-xx  every  hour  or  two  hours. 
There  are^  unfortunately,  no  special  indications  for  its 
use ',  but  it  seems  to  be  more  efficacious  when  the 
second  and  third  divisions  are  affected  than  in  neuralgia 
of  the  ophthalmic  division.  Aconitine  may  be  used 
hypodermically,  in  doses  of  nt  j-iv  of  a  solution  contain- 
ing gr.  j  in  5  iv  of  distilled  water  with  a  little  sulphuric 
acid. 

As  specific  remedies  we  may  choose  between 
quinine^  salicylate  of  sodium,  arsenic,  and  iron.  When- 
ever periodicity  is  a  feature  of  the  attacks,  quinine  in 
full  doses  (gr.  x-xv)  should  be  given  several  hours 
before  the  pain  usually  comes  on.  It  may  be  ad- 
vantageously combined  with  the  hydrobromic  acid.  For 
similar  cases  the  salicylate  of  sodium  may  be  employed 
in  doses  of  thirty  or  forty  grains.  Arsenic  comes  next 
in  efficacy  and  should  be  tried  whenever  quinine  and 
the  salicylate  fail.  Fowler^s  solution  should  be  given  in 
doses  of  from  nxv-x  three  times  a  day.  Iron  is  most 
generally  useful  whenever  there  is  marked  anaemia,  but 


2.32        teieatmi:nt  of  facial  neuralgia. 

it  sometimes  does  good  when  the  latter  is  not  a 
prominent  symptom.  Chloride  of  ammonium  in  doses 
of  gr.  xx-xxx^  several  times  a  day,  is  also  recommended. 
Anodyne  remedies,  applied  externally,  are  sometimes 
useful  as  palliatives.  A  stick  of  menthol,  the  liniments 
of  aconite,  belladonna,  opium,  and  chloroform  are 
available  for  this  purpose.  Counter-irritation,  by  means 
of  blisters  at  the  back  of  the  neck  or  behind  the  ears, 
sometimes  affords  relief. 

When  all  other  measures  have  failed  to  afford  relief, 
and  the  pain  renders  the  patient's  life  very  miserable, 
operative  treatment  may  be  had  recourse  to  in  the  form 
either  of  neurotomy,  or  simple  division  of  the  nerve, 
neurectomy,  or  excision  of  a  portion,  or  nerve-stretch- 
ing. Of  these  neurectomy  yields  the  best  results. 
Before  performing  either  this  operation  or  simple 
incision,  it  is  desirable  to  ascertain  as  far  as  possible 
the  existence  and  position  of  any  local  cause  for  the 
neuralgia,  for  to  be  successful  the  operation  must  be 
performed  on  the  central  side  of  any  such  spot.  In 
nerve-stretching  we  are  able  to  act  from  the  periphery 
upon  the  more  central  portions  of  the  nerve ;  but  this 
operation  in  cases  of  facial  neuralgia  has  seldom  been 
followed  by  satisfactory   results.     With   regard  to  neu- 


INTERCOSTAL  NEURALGIA.  233 

rectomy,  it  has  been  noticed  that  after  an  operation  on 
one  division  of  the  nerve  another  division  has  become 
the  seat  of  very  severe  pain. 

II.  Intercostal  Neuralgia. 
This  is  the  name  given  to  neuralgic  pain  affecting 
the  nerves  in  some  of  the  intercostal  spaces ;  it  is  most 
frequently  felt  on  the  left  side^  and  in  the  spaces  from 
the  fifth  to  the  ninth  downwards.  It  rarely  occurs  on 
both  sides_,  or  in  a  single  space ;  generally  two  or  three 
neighbouring  nerves  are  affected  at  the  same  time.  The 
reason  for  the  left  side  being  more  commonly  affected 
is  said  to  be  that  the  venous  blood  of  its  lower  inter- 
costal spaces  passes  by  a  more  circuitous  route  into  the 
vena  cava,  viz.,  by  the  small  vena  azygos.  This  form 
of  neuralgia  is  most  frequent  in  persons  between  twenty 
and  forty  years  of  age,  and  is  much  more  common  in 
women  than  in  men,  but  I  have  seen  several  cases  of 
severe  intercostal  neuralgia  in  male  subjects.  It  is 
especially  apt  to  occur  in  those  who  sit  closely  at  work 
and  take  little  exercise,  but  it  is  also  noticed  in  persons 
living  under  different  conditions,  viz.,  in  those  whose 
rest  and  food  are  alike  deficient.  Certain  constitutional 
disorders  predispose  to  intercostal  neuralgia,  and  among 
them  may   be   mentioned  syphilis,   gout,  and  anaemia. 


234       SYMPTOMS  OF  INTERCOSTAL  NEURALGIA. 

especially  when  due  to  prolonged  lactation,  or  to 
chronic  gastric  catarrh.  In  some  instances  the  pain 
may  be  traced  to  exposure  to  cold.  Local  affections, 
such  as  injuries  to  the  ribs^  caries  and  morbid  growths, 
diseases  of  the  pleurae  and  lungSj  especially  tuberculosis, 
disorders  of  the  liver,  affections  of  the  spinal  cord  and 
its  membranes,  are  all  likely  to  cause  pain  in  the  inter- 
costal spaces,  though  not  necessarily  of  a  purely 
neuralgic  character. 

There  is  a  close  connection  between  affections  of  the 
uterus  and  ovaries  and  neuralgia  in  the  intercostal 
spaces.  In  some  patients  suffering  from  profuse 
menstruation  the  pain  invariably  comes  on  during  the 
monthly  periods,  and  ceases  with  the  discharge.  In 
cases,  too,  of  dysmenorrhoea,  dependent  upon  stenosis 
of  the  cervical  canal,  intercostal  neuralgia  is  sometimes 
present,  and  is  cured  by  dilating  the  cervix.  Pain  in 
the  intercostal  spaces  is  a  common  symptom  of  spinal 
irritation.  The  affection  termed  ''  irritable  breast  '^  is 
a  form  of  intercostal  neuralgia,  the  pain  being  localized 
in  one  or  other  of  those  organs.  This  complaint  occurs 
almost  exclusively  in  young  women,  and  is  apt  to. 
complicate  hysteria  and  various  uterine  disorders. 

Symptoms.     The   pain   is    felt  in    the  course   of  the 


SYMPTOMS  OF  INTERCOSTAL  NEURALGIA.       235 

nerves  affected,  and  may  be  either  continuous  or 
paroxysmal  in  character.  In  the  former  case  there  are 
generally  sharper  twinges  at  irregular  intervals  ;  there  is 
often  some  amount  of  cutaneous  hypersesthesia  in  the 
aiFected  region,  and  pressure  over  the  spinous  processes 
of  the  corresponding  vertebrs  sometimes  produces 
severe  pain.  Sometimes  the  pain  is  confined  to  one  or 
more  points^  and  these  are  usually  in  the  axillary  lines 
or  just  below  the  breasts.  Tender  points  are  frequently 
discoverable  in  one  or  more  of  the  following  situa- 
tions : — T.  Over  the  spot  where  the  nerve  escapes  from 
the  intervertebral  foramen.  2.  At  a  point  midway 
between  the  vertebral  column  and  the  sternum,  where 
the  superficial  branches  are  given  off.  3.  Near  the 
sternum,  or  further  down  at  the  edge  of  the  rectus 
muscle,  where  the  nerve  ends  in  cutaneous  branches. 
The  pain  is  aggravated  by  movements  of  various  kinds, 
and  especially  by  coughing  and  sneezing.  Difficulty  of 
breathing  is  sometimes  complained  of;  the  patient  finds 
that  full  inspirations  increase  the  pain  or  cause  a 
paroxysm.  In  not  a  few  cases  the  affected  nerves  are 
very  sensitive  to  pressure  throughout  the  whole  length 
of  the  intercostal  spaces;  sometim.es,  indeed,  the 
slightest  touch  causes  the  side  to  be  forcibly  retracted. 


236       SYMPTOMS  OF  INTERCOSTAL  NEURALGIA. 

On  the  other  hand^  it  may  happen  that  firm  pressure 
relieves  or  even  removes  the  pain  for  a  time. 

Irradiation  of  the  pain  towards  the  back  and  to  the 
scapula  is  of  frequent  occurrence_,  and  the  arm  and 
breast  are  also  liable  to  be  affected.  The  second 
intercostal  nerve .  communicates  with  the  internal 
cutaneous  nerve  of  the  arm,  and  several  of  these  nerves 
send  lateral  branches  to  the  breast.  Frequency  of 
respiration  sometimes  occurs  in  connection  with  inter- 
costal neuralgia,  and  painful  attacks  of  palpitation  of 
the  heart  are  occasionally  associated  with  this  latter 
affection.  I  have  recently  had  under  my  care  a  man, 
age  ^8,  of  gouty  habit  and  family  history,  suffering  from 
occasional  paroxysms  of  intercostal  neuralgia.  These 
were  accompanied  by  severe  burning  pain  in  the  cardiac 
region,  anid  palpitation  of  the  heart.  The  patient  went 
from  one  physician  to  another,  fully  convinced  that  he 
had  heart  disease  and  angina  pectoris.  All  his  symptoms 
disappeared  under  iodide  of  potassium,  gr.  v,  t.d.,  flying 
blisters,  and  a  carefully  regulated  diet.  It  would  seem 
probable  that  through  reflex  action  such  local  attacks 
of  pain  may  not  only  influence  the  function,  but  by 
degrees  produce  altei'ations  in  the  structure  of  the 
heart. 


DIAGNOSIS  OF  INTERCOSTAL  NEURALGIA.      237 

With  regard  to  complications,  herpes  zoster  is  the 
one  most  frequently  observed.  It  is  notj  of  course,  to 
be  regarded  as  the  cause  of  the  neuralgia,  inasmuch  as 
the  latter  may  exist  alone^  and  often  precedes  the 
eruption  by  several  weeks.  On  the  other  hand,  the 
herpes  may  appear  along  the  course  of  one  or  more 
intercostal  nerves  without  any  accompanying  pain,  and 
this  is  generally  seen  in  children.  In  old  people  the 
herpes  is  apt  to  precede  the  neuralgia,  which  continues 
after  the  sores,  left  by  the  eruption,  have  healed,  and  is 
often  extremely  obstinate. 

Nothing  can  be  definitely  asserted  with  regard  to  the 
course  of  intercostal  neuralgia.  It  is  always  tedious 
and  sometimes  very  protracted :  patients  are  apt  to 
become  very  anxious,  and  often  imagine  that  some 
severe  disease  of  the  lungs  or  breast  is  the  cause  of  the 
pain.  The  prognosis  is  therefore  not  very  favourable, 
and  the  older  the  patient  the  more  obstinate  the  com- 
plaint. 

Diagjmsis.  The  points  to  be  determined  are  :  ist, 
whether  we  have  a  case  of  intercostal  neuralgia  to  deal 
with ;  and,  2ndly,  the  cause  of  the  suffering.  With 
regard  to  the  first  point,  the  pain  might  be  due  to 
pleurisy,  but  careful  examination  with  the  stethoscope 


238  MASTODYNIA. 

will  prevent  any  such  mistake.  In  so-called  rheumatism 
of  the  muscles  of  the  chest  the  parts  will  be  very  sensi- 
tive to  pressure.  When  the  heart  itself  is  the  seat  of 
the  pain,  the  latter  will  be  felt  principally  in  the  pre- 
cordial region^  and  will  be  accompanied  by  evidences  of 
weakness  (small  pulse,  feeble  heart  sounds),  and  great 
irritability  of  the  organ.  In  all  cases  the  ribs  should 
be  very  carefully  examined  in  order  to  determine  the 
presence  or  absence  of  fracture,  caries,  or  periostitis. 
The  vertebral  column,  too,  should  not  be  neglected,  for 
incipient  caries  often  gives  rise  to  intercostal  pain, 
which  if  felt  mainly  in  the  front  of  the  thorax  may  be 
attributed  to  the  heart,  lungs,  or  stomach.  By  passing 
the  finger  backwards  along  the  affected  intercostal 
spaces  a  sensitive  spot  will  be  detected  near  the  verte- 
bral column. 

Irritable  breast  or  mastodynia  is  an  affection  of  the 
anterior  cutaneous  branches  of  the  upper  intercostal 
nerves,  and  the  supra-clavicular  branches  of  the  fourth 
cervical  nerve  are  also  liable  to  be  implicated.  It  is 
one  of  the  most  obstinate  and  painful  forms  of 
neuralgia,  and  the  pain  is  apt  to  radiate  to  the  arm  and 
neck.  The  attacks  may  last  for  several  hours,  and  be 
separated  from  each  other  by  only  short  intermissions 


MASTODYNIA.  239 


or  remissions.  In  some  of  these  cases  the  spinous 
processes  of  the  last  cervical  and  first  dorsal  vertebrae 
are  very  tender  on  pressure,  and^  as  a  general  rule,  the 
whole  breast  is  more  or  less  acutely  sensitive.  Even 
contact  with  the  clothes  is  sometimes  almost  unbear- 
able. Movement  of  the  arm  increases  the  pain,  which 
is  accompanied  by  a  sensation  of  weight  in  the  breast. 
The  causes  of  mastodynia  are  very  obscure ;  the  affec- 
tion is  most  common  in  young  girls  at  the  time  of 
puberty,  and  up  to  twenty-five  or  thirty  years  of  age; 
it  is  rare  in  women  of  middle  age.  When  it  occurs  in 
these  latter  subjects  it  is  sometimes  due  to  hyperlactation, 
and  under  these  circumstances  the  left  breast  is  generally 
affected.  The  complaint  is  not  unfrequently  associated 
with  disorders  of  menstruation,  but  it  likewise  occurs 
in  the  absence  of  any  such  complication.  Local  causes, 
such  as  injuries  of  various  kinds,  are  sometimes  assigned 
for  the  occurrence  of  the  symptoms,  but  the  relation- 
ship is  for  the  most  part  doubtful.  It  often  happens 
that  careful  examination  of  the  dand  will  detect  one  or 
more  small  hard  nodules,  very  sensitive  to  pressure, 
and  varying  in  size  from  that  of  a  pea  to  that  of  a 
hazel-nut.  Nothing  is  positively  known  as  to  the 
nature  of  these  swellings,  and  they  have  been  supposed 


240     TREATMJENT  OF  INTERCOSTAL  NEURALGIA. 

to  be  neurornata  or  tubercula  dolorosa  of  the  nerves 
of  the  breast.  Their  size  and  tenderness  are  both 
increased  at  the  commencement  of  menstruation. 
They  are  by  no. means  always  present  in  these  cases  of 
mastodynia ;  pain  and  tenderness  of  equal  severity  may 
exist  in  their  absence. 

The  differential  diagnosis  in  cases  of  mastodynia  mav 
present  some  difficulties ;  but  careful  observation  will 
serve  to  decide  the  nature  of  the  case.  The  pain  re- 
sembles that  of  malignant  disease,  and  the  existence 
of  hard  nodules  tends  to  corroborate  the  fears  of  the 
patient  and  her  friends.  In  malignant  disease,  however;? 
the  growth  always  increases  in  size  with  more  or  less 
rapidity  j  it  never  remains  circumscribed,  and^  of  course^ 
never  disappears,  as  is  often  the  case  with  the  growths 
under  consideration.  Smal>and  deeply-seated  abscesses 
mav  be  mistaken  for  these  tumours  of  mastodynia,  but 
their  course  soon  reveals  their  true  nature.  The  sensi- 
tiveness of  the  part  in  neuralgia  of  the  breast  is  char- 
acteristic j  it  is  more  marked  than  in  any  other  affection 
of  the  gland. 

In  the  treatment  of  intercostal  neuralgia  the  part 
should  be  carefully  examined,  in  order  that  any  existing 
local   cause  may  not  be   neglected.     Attention  should 


TREATMENT  OF  INTERCOSTAL  NEURALGIA.     241 

next  be  paid  to  constitutional  conditions^  e.g.,  syphilis 
and  gout,  and  to  the  presence  of  any  hepatic,  uterine, 
or  other  abdominal  disorder.       All   these    will  require 
appropriate  treatment.   Whenever  symptoms  of  anaemia 
or  chlorosis  are  present,  tonics  of  all  kinds,  and  especi- 
ally iron,  are  indicated.   When  amenorrhoea  exists  aloes 
is  likely  to  be  suitable,  and  may  be  combined  with  the 
iron.     It  seldom  happens  that  general  treatment  of  any 
kind  is  sufficient  to  cure  intercostal  neuralgia.  Measures 
designed   to   relieve  the  pain  are  almost  always  indis- 
pensable.    Of  these  the  most  efficacious  is  the  hypo- 
dermic injection  of  morphine,  though  its  results  are  for 
the  most  part  only  temporary.     Other  anodynes,  e.g., 
aconite,   belladonna,  and    chloroform,  may   be   applied 
locally  as  liniments.     If  these  measures  fail  to  relieve, 
electricity  should   be  tried;   and,   first,  the  continuous 
current,   the   positive  pole  being  applied  close   to   the 
vertebrae  and  the  negative  to  the  lower  border  of  the  ribs 
in  the  affected  spaces.    The  induced  current  may  be  ap- 
plied in  the  form  of  the  faradic  brush.      In  very  obstinate 
cases  blisters  are  likely  to  be  serviceable.  Herpes  zoster 
is  rather  a  favourable  complication  than  otherwise,  for 
the  pain  generally  subsides  when  the  blisters  left  by  the 
vesicles  heal  up.     For  mastodynia  it  is  often  necessary 

16 


242  SCIATICA. 


to  try  one  remedy  after  another  until  a  suitable  one  is 
met  with.  As  a  general  rule,  the  pain  is  relieved  by 
warmth  and  by  bandaging  the  breast.  A  stream  of 
warm  water  should  be  allowed  to  play  upon  the  painful 
spot  for  fifteen  minutes  twice  a  day,  and  after  carefully 
drying  the  skin  belladonna  liniment  should  be  applied, 
and  afterwards  cotton-wool  and  a  bandage.  Electricity 
may  likewise  be  tried  in  the  form  of  the  faradic  brush  or 
the  constant  current.  If  the  latter,  the  negative  pole  is 
placed  on  the  vertebral  column  over  any  sensitive  spot, 
and  the  other  pole  applied  to  the  breast.  In  all  cases 
the  general  health  should  be  attended  to,  and  the 
patient's  mind  diverted  as  far  as  possible  from  her 
ailment.  A  short  course  of  the  bromides  is  likely  to  be 
serviceable;  it  will  tend  to  lessen  the  hyperaesthesia  in 
the  gland,  as  well  as  general  irritability. 

III.  Sciatica. 
Next  to  tic  douloureux,  sciatica  is  the  most  common 
form  of  neuralgia,  and  it  has  this  peculiarity,  that  the 
pain  is  felt  mainly  in  the  trunk  of  the  nerve,  and  either 
not  at  all  or  in  a  less  degree  in  its  branches  of  distribu- 
tion. The  frequency  of  the  affection  is  due  to  the 
exposed  and  superficial  position  of  the  nerve ;  but  it 
would  appear  that  in  many  cases  the  mischief  is  seated 


CAUSES  OF  SCIATICA:  243 

in  the  surrounding  parts  rather  than  in  the  nerve  itself. 
The  term  is  somewhat  loosely  used;  it  has,  for  in- 
stance, been  pointed  out  by  Mr.  Hutchinson  that 
inflammatory  affections  of  the  hip-joint  are  the  real 
cause  of  the  symptoms  in  some  cases  of  supposed 
sciatica.  The  affection  is  important,  not  only  because 
of  the  pain — often  very  severe — but  also  because  of  the 
incapacity  for  movement  which  results  therefrom. 

With  regard  to  the  causation  of  sciatica,  the  com- 
plaint is  sometimes  directly  traceable  to  the  influence  of 
cold  and  moisture.  Standing  in  cold  water,  sitting  on 
damp  grass,  or  on  cold  stones,  or  wet  seats  are  common 
causes  of  an  attack.  Injuries  to  the  hip  or  thigh,  and 
continuous  pressure  upon "  the  nerve,  caused,  e.g.,  by 
sitting  on  a  hard  seat,  are  sometimes,  though  less  often, 
followed  by  similar  consequences.  After  difficult  labours 
and  the  use  of  instruments  for  delivery,  a  troublesome 
attack  of  sciatica  has  been  known  to  supervene,  as  a 
result  of  pressure  upon  the  nerve  in  the  pelvis.  The 
growth  of  tumours,  either  within  or  external  to  the 
pelvis,  may  produce  the  same  effect.  Some  cases  are 
attributable  to  over-exertion  of  the  lower  limbs,  as  in 
walking  or  climbing  and  in  working  machines  with  the 
foot.      Constitutional    disorders,   notably  syphilis   and 


244  G^  USES  OF  S  CIA  TIC  A . 

gout,  predispose  to  sciatica;  and  in  the  former  of  these 
gummatous  growths  are  sometimes  found  in  connection 
with  the  nerve.  The  presence  of  hard  faecal  masses  in 
the  colon  and  rectum,  and  dilatation  and  congestion  of 
the  veins  of  the  pelvis^  are  common  causes  of  sciatica. 
Many  of  these  veins  are  destitute  of  valves,  and  are 
especially  liable  to  periodical  attacks  of  congestion  in 
various  disordered  conditions  of  the  abdominal  organs, 
notably  the  liver.  The  connection  between  sciatica  and 
abdominal  affections  has  long  been  recognized^  and  the 
venous  plethora  is  the  connecting  link.  Constipation 
often  precedes  an  attack,  which  is  relieved  when  the 
former  condition  is  removed.  In  some  cases  of  sciatica 
the  venous  stasis  extends  to  the  affected  limb^  the  veins 
of  which  from  the  foot  upwards  are  enlarged  and 
varicose. 

As  might  be  expected^ -sciatica  is  more  common  in 
winter  than  in  summer^  and  the  majority  of  the  patients 
are  of  the  male  sex.  The  complaint  is  rare  before 
puberty^  and  generally  occurs  in  patients  over  thirty 
years  of  age.  Conditions  of  anaemia  do  not  seem  to 
predispose  to  it^  as  is  the  case  with  facial  and  intercostal 
neuralgia.  The  complaint  is  sometimes  met  with  in 
persons  suffering  from  the  effects  of  mercury  and  those 


SYMPTOMS  OF  SCIATICA.  245 

of  lead^  but  the  brachial  neives  are  more  prone  to  be 
affected  in  these  cases.     Pain  alonsr  the  course  of  the 

o 

sciatic    nerves    is    not    unfrequent   in   diseases    of   the 
vertebrce  and  of  the  spinal  cord. 

The  prominent  symptom  of  sciatica  is  the  pain  which 
extends  over  the  greater  portion  of  the  course  of  the 
sciatic  nerve.  It  is  rarely  confined  to  one  portion, 
though  it  may  be_,  and  often  is,  more  severe  at  the  back 
of  the  thigh  than  in  the  leg  or  foot.  There  are  generally 
some  premonitory  symptoms^  such  as  numbness, 
tingling,  or  slight  and  transient  pain  along  the  course 
of  the  nerve.  The  pain  often  begins  at  the  sides  of  the 
vertebral  column,  where  it  takes  the  form  of  lumbago  ;  it 
thence  gradually  spreads  downwards  to  the  thigh,  leg, 
and  foot.  In  exceptional  cases  the  pain  begins  below 
and  spreads  upwards.  The  pain  is  sometimes  con- 
tinuous, sometimes  paroxysmal,  with  intervals  of 
immunity.  It  is  usually  worse  at  night,  and  is 
variously  described  by  patients  as  of  a  burning,  piercing, 
screwing,  or  stinging  character.  The  attacks  often 
come  on  spontaneously,  but  are  almost  invariably 
excited  by  movements  of  the  liinb  and  pressure.  The 
course  of  the  nerve  is  sometimes  exquisitely  tender. 
In  severe  cases,   owing  to  the  paiii    which  is  caused. 


246  SYMPTOMS  OF  SCIATICA. 

inovement  of  the  limb  is  impossible;  in  slighter  forms 
the  patient  walks  with  his  knee  bent.  The  pain  is 
almost  always  worse  on  attempting  to  move  the  limb 
after  it  has  been  kept  for  some  time  in  one  position. 
Coughing  and  sneezing  are  apt  to  provoke  a  severe 
paroxysm.     The  attacks  are  not  attended  with  pyrexia. 

The  symptoms  are  not  always  so  acute  as  those- 
above  described.  In  some  cases  the  pain  is  not  such  as 
to  confine  the  patient  to  his  bed,  or  to  prevent  him 
from  following  his  occupation.  A  sensation  of  aching 
or  soreness  in  the  back  of  the  thigh  and  a  feeling  of 
stiffness  are  the  principal  symptoms_,  and  these  vary  in 
degree  from  time  to  time^  last  for  an  indefinite  period, 
and  never  become  very  severe.  In  the  acute  form,  on 
the  other  hand,  the  pain  is  often  of  an  intense  character,, 
and,  especially  when  occurring  in  a  person  unaccustomed 
to  suffering,  is  apt  to  produce  great  mental  distress. 

The  extension  of  the  pain  along  the  various  branches- 
of  the  nerve  varies  much  in  different  cases.  From  the 
back  of  the  thigh  the  pain  may  spread  either  to  the 
internal  or  external  popliteal  branches.  Sometimes  the 
calf  of  the  leg  is  the  seat  of  acute  pain ;  while  in  other 
cases  the  plantar  branches  of  the  posterior  tibial  nerve 
are  especially  affected.     Moreover,   the  pain  is  apt  to- 


SYMPTOMS  OF  SCIATICA.  247 

shift  its  seat  from  time  to  time,  without  altogether 
leaving  the  spot  in  which  it  first  appeared.  The  left 
leg  is  somewhat  more  frequently  attacked  than  the 
right,  but  the  difference  in  the  liability  is  not  very 
great.  In  a  small  proportion  of  cases  both  legs  are 
affected . 

With  regard  to  the  existence  of  points  douloureux 
these  are  generally  to  be  detected  in  cases  of  sciatica. 
The  most  important  is  situated  near  the  posterior 
superior  spine  of  the  ilium  ;  another  is  between  the 
tuberosity  of  the  ischium  and  the  trochanter  major. 
Others  are  to  be  found  behind  the  head  of  the  fibula 
and  behind  the  malleoli.  Pressure  in  the  middle 
line  of  the  popliteal  space  also  frequently  causes 
pain.  In  some  cases  there  is  increased  sensitiveness  on 
pressure  diffused  over  the  back  of  the  limb,  and  with 
this  some  amount  of  diminution  of  tactile  sensibility 
and  of  the  temperature  sense  is  apt  to  be  associated. 
In  some  cases  the  sense  of  temperature  is  perceptibly 
heightened.  Such  a  patient,  standing  with  his  back  to 
the  fire,  finds  the  warmth  unbearable  on  the  affected 
side.  The  muscles  of  the  limb  and  the  vaso-motor 
and  trophic  nerves  seldom  remain  unaffected  in  cases 
of  sciatica.     The  flexor  muscles  of  the  thiofh  and  the 


248  SYMPTOMS  OF  SCIATICA. 

muscles  of  the  leg  are  stiff  and  tense,  and  motion  is 
difficult,  even  when  the  pain  is  not  of  itself  sufficient 
to  prohibit  it.     This  condition  of  the  muscles  can  be 
observed  when  subjecting  the  limb  to   passive  move- 
ments, and  it  is  apt  to  remain  for  some  time  after  the 
acute  symptoms  have  subsided.    The  gait  of  the  patient 
is  often  peculiar;  he  walks  with  the  knee  bent,  and  the 
pelvis  on  the  aff^ected  side  lower  than  on  the  other.     In 
this  position  extension  of  the  muscles  is  avoided,  and 
the  nerve  and  its  main  branches  are  not  liable  to  be 
compressed.      In    chronic    cases  this   position^   unless 
steps  be  taken  to  remedy  it^  is  likely  to  become  per- 
manent and  to  cause  more  or  less  lameness.     Spasms 
of  the  muscles  of  the  calf  and  fibrillary  twitchings  of 
the  flexor  muscles  of  the  thigh  are  sometimes  observed. 
With  regard  to  the  vaso-motor  and  trophic  symptoms, 
these  vary  in  character  in  difl^erent  cases  and  at  diff^srent 
periods  in  the  same  patient.     The  temperature  of  the 
leg  and  foot  on  the  affected  side  is  sometimes  increased, 
sometimes  diminished  ;  the  colour  may   be  either  pale, 
or  there  may  be  patches  of  redness  or  diffused  colora- 
tion ;    the   secretion  from  the  skin  is  either  increased 
or   diminished.       The  surface    is    sometimes    dry    and 
brittle ;    in    other    cases    it    is    moist,    and     the    foot 


SYMPTOMS  OF  SCIATICA.  249 

especially  is  covered  with  copious  perspiration.  It  is 
curious  that  two  such  opposite  conditions  should  occur 
in  the  same  affection.  In  some  cases  after  the  com- 
plaint has  existed  for  a  few  weeks  decided  atrophy  of 
the  muscles  supplied  by  the  sciatic  nerve  sets  in.  In 
these  cases  neuritis  most  probably  exists.  On  the 
other  hand^  hypertrophy  of  the  muscles  has  sometimes 
been  noticed.  Other  evidences  of  disorder  of  the 
trophic  nerves  are  sometimes  supplied  by  the  occurrence 
of  various  forms  of  eruption^  e.g.,  erythema^  erysipelas, 
herpes_,  etc. 

A  remarkable  symptom,  probably  indicative  of 
disorder  of  vaso-motor  nerves,  is  sometimes  noticed  in 
connection  with  sciatica ;  the  urine  is  found  to  contain 
a  small  amount  of  sugar.  The  condition  is  usually 
transient,  subsiding  as  the  pain  ceases  to  be  trouble- 
some. The  complication  has  been  observed  in  cases  in 
which  the  sciatica  was  a  symptom  of  some  spinal 
affection  ;  but  it  has  also  been  noticed  in  simple  cases, 
due  probably  to  venous  hyperaemia  within  the  abdomen, 
and  particularly  in  the  portal  circulation.  I  have 
recently  attended  three  cases  in  which  this  symptom 
was  present. 

In   cases  of  sciatica  certain  changes  are  sometimes 


250  COURSE  OF  SCIATICA. 

__ • ■       . — 

noticed  in  the  electrical  condition  of  the  affected  parts, 
especially  when  evidences  of  disordered  nutrition  are  in 
any  way  prominent.  The  faradic  contractility  of  the 
muscles  is  diminished ;  the  cutaneous  sensibility  is  at 
first  increased,  but  afterwards  lessened.  The  reaction 
to  galvanism  varies;  in  cases  due  to  neuritis  the  ex- 
citability is  at  first  increased  and  afterwards  much 
diminished. 

The  course  and  duration  of  sciatica  are  liable  to  great 
variations.  The  pains  generally  disappear  in  the  same 
order  in  which  they  came  on,  remaining  in  the  lower 
parts  of  the  limb  for  some  time  after  they  have  ceased 
in  the  thigh.  In  some  cases  the  last  symptom  is  some 
amount  of  ancesthesia  dolorosa  of  the  toes.  During  the 
course  of  the  complaint  the  pain  is  apt  to  radiate  along 
other  nerves ;  sometimes  the  other  side  is  affected,, 
sometimes  an  arm.  Lumbago  is  likewise  a  frequent 
complication.  The  course  of  the  complaint  is  of  an  in- 
definite character ;  it  usually  extends  to  several  weeks,, 
in  spite  of  treatment ;  sometimes  it  lasts  for  several 
months,  or  even  years.  In  cases  due  to  cold,  recovery 
is  the  rule ;  but  when  the  cause  is  a  pelvic  tumour  the 
sciatica  is  persistent.  In  all  severe  cases  more  or  less 
weakness  and  wasting  of  the  limb  may  be  expected  ta 


DIAGNOSIS  OF  SCIATICA.  251 

remain  for  some  time  after  the  paiu  has  ceased.  Re- 
lapses are  very  prone  to  occur^  but  instances  are  not 
unfrequent  in  which,  after  many  weeks  of  very  severe 
sufferings  there  is  complete  immunity  from  further 
attacks. 

Diagnosis.  This  is  for  the  most  part  easily  made, 
but  mistakes  sometimes  occur.  In  sciatica  the  pain 
follows  the  course  of  the  nerve^  and  is  not  dependent 
on  muscular  action.  The  lightning-like  pains  of  loco- 
motor ataxy  more  or  less  resemble  those  of  sciatica ; 
but  the  absence  of  patellar  reflex  is  characteristic  of 
the  former  affection.  Sciatica  is  most  apt  to  be  con- 
founded with  disease  of  the  hip-joint.  In  the  latter 
the  pain  produced  in  the  part  by  movement^  the 
shortening  of  the  limb_,  and  the  position  it  generally 
assumes,  are  the  points  to  be  contrasted  with  the  main 
features  of  sciatica.  The  history  of  the  case  will  also 
aid  the  diagnosis,  and  the  same  remark  applies  to  cases 
in  which  a  paretic  state  of  the  limb  has  given  rise  to  a 
suspicion  of  paralysis.  In  sacro-iliac  disease,  in  which 
there  is  often  severe  pain  in  the  thigh,  the  patients  are 
alwavs  voung,  and  a  careful  examination  will  detect  the 
source  of  the  mischief.  Besides  the  affections  already 
mentioned,  it  must  be  remembered  that  pain  along  the 


252  TRIIATMENT  OF  SCIATICA. 

course  of  the  sciatic  nerves  is  a  frequent  symptom  of 
pelvic  tumours^  aneurisms^  etc.  Dr.  Buzzard  has 
pointed  out  that  myalgia  of  the  flexor  muscles  of  the 
thigh,  and  muscular  rheumatism  in  the  same  muscles, 
closely  resemble  sciatica.  They  differ  from  it^  however, 
in  the  fact  that  the  pain  is  situated  especially  at  the 
points  of  attachment  of  the  muscles,  and  is  not  spon- 
taneous, but  is  felt  only  when  the  muscles  are  in  action. 

The  prognosis  is  favourable  in  the  majority  of  cases  of 
sciatica.  When  the  attack  is  directly^  traceable  to  an 
obvious  cause,  e.g.,  exposure  to  cold  and  damp,  prompt 
treatment  generally  yields  the  happiest  results.  Even 
chronic  cases  are  almost  always  amenable  to  treatment, 
though  relapses  are  prone  to  occur;  and  for  some  time 
after  the  pain  has  subsided  there  is  often  more  or  less 
discomfort  in  the  limb  and  a  feeling  of  weakness.  The 
affected  limb  soon  becomes  tired,  and  weeks  or  even 
months  may  elapse  before  it  recovers  its  normal  con- 
dition. In  cases  dependent  upon  serious  lesions  in  the 
pelvis,  the  prognosis  is,  of  course,  of  a  different  cha- 
racter. 

The  treatment  is  more  satisfactory  than  that  of  most 
other  forms  of  neuralgia,  and  local  remedies  are 
often    of  signal    service.      A    vast    number   of    means 


tri:atment  of  sciatica.  253 

have  been  recommended,  and  the  difficulty  is  to 
select  the  one  most  appropriate.  The  first  step  is  to 
endeavour  to  ascertain  the  cause,  and  for  this  pur- 
pose the  affected  limb  must  be  carefully  examined 
in  order  to  discover  whether  there  are  any  local  affec- 
tions connected  with  the  nerve  or  its  branches.  Should 
such  exist  the  question  of  their  removal  by  operation 
will  have  to  be  entertained.  The  general  condition  of 
the  patient  is  the  next  point  to  be  studied.  If  there  be 
evidences  of  congestion  of  the  pelvic  veins,  or  of  the 
portal  system,  purgatives  are  especially  indicated^  and 
of  these  the  sulphates  of  sodium  and  magnesium  are  the 
most  appropriate.  Carlsbad  salts  form  a  very  suitable 
combination,  more  particularly  for  gouty  subjects  in 
whom  an  attack  of'sciatica  is  likely  to  be  due  to  hepatic 
congestion.  In  such  cases  two  or  three  grains  of  blue 
pill  should  be  given  at  bed-time  for  three  or  four  nights, 
and  a  dose  of  the  salts  in  the  morning.  The  bowels 
should  be  thoroughly  cleared  out,  but  drastic  purgatives 
are  to  be  avoided.  Salines  will  also  be  found  suitable 
for  non-gouty  cases  in  whom  constipation  is  a  pro- 
minent symptom,  but  other  purgatives,  such  as  extract 
of  aloes  and  castor  oil,  mav  also  be  used. 

In  rheumatic  subjects,  iodide  of  potassium  or  sodium 


2  54  TREATMENT  OF  SCIATICA. 

will  probably  be  found  the  best  remedy,  doses  of  from 
fiv^e  to  ten  grains  three  times  a  day  being  usually  suffi- 
cient. It  is  well  to  add  a  little  bicarbonate  to  the 
iodide,  and  the  disagreeable  effects  which  the  latter  some- 
times produces  may  frequently  be  prevented  by  giving 
three  or  four  minims  of  tincture  of  belladonna  with 
each  dose.  Another  way  of  administering  the  iodide 
is  to  give  it  in  seltzer- water.  Where  there  is  great  pain 
I  have  prescribed  salicylate  of  sodium  in  doses  of  20 
grains  every  four  or  six  hours  with  much  benefit. 
Blisters  are  also  particularly  indicated  in  this  class  of 
cases,  and  the  best  method  of  using  them  is  to  apply 
the  liquor  epispasticus  over  circular  spots  about  two 
inches  in  diameter  down  the  course  of  the  nerve.  If 
there  be  marked  tenderness  at  any  one  spot  the  blister 
should  be  made  at  some  little  distance  from  it.  When 
the  acute  attack  has  subsided  warm  baths  are  almost 
always  serviceable.  In  anaemic  and  chlorotic  subjects 
tonics  such  as  iron  and  quinine  are  invariably  required 
in  addition  to  local  remedies.  For  cases  in  which  there 
is  a  history  of  syphilis  a  course  of  the  iodides  will  be 
found  efficacious. 

Much  may  be  done  by  way  of  palliation  in  all  cases 
of  sciatica,  and  the  hypodermic  injection  of  morphine 
is  probably  the  most  potent  remedy   of  this  class  that 


TREATMENT  OF  SCIATICA.  255 

we  possess.  It  is  advisable,  and  generally  practicable, 
to  make  the  injections  close  to  the  seat  of  the  acutest 
pains,  for  the  morphine  has  a  local  as  well  as  a  general 
anodyne  action.  If  the  morphine  fail  to  giv^e  relief,  or 
if  it  produce  distressing  head-symptoms,  atropine  may 
be  tried,  gr.  -^^  for  each  injection.  For  some  cases  a 
combination  of  the  two  drugs  acts  satisfactorily.  The 
atropine  counteracts  the  unpleasant  effects  of  the 
morphine  upon  the  head  and  stomach. 

Electricity  is  sometimes  valuable  for  the  relief  of 
sciatica;  but  its  action  in  this  respect  is  very  un- 
certain, and  therefore  it  is  impossible  to  foretell  its 
effects  in  any  given  case.  In  recent  attacks  the  continu- 
ous current  sometimes  produces  marked  beneficial  effects. 

Dr.  Buzzard,  in  an  excellent  paper  on  Sciatica,  which 
appeared  in  the  Practitioner  for  February,  1877,  states 
that  the  application  is  most  hopeful  in  those  cases  of 
sciatica  which  are  not  dependent  upon  obvious  causes 
of  peripheral  irritation,  but  that  it  may  be  useful  in 
cases  belonging  to  the  latter  class.  Dr.  Buzzard  gives 
the  following  rules  for  the  application  of  the  constant 
current  for  the  relief  of  sciatica.  From  20  to  40  cells 
are  required,  but  when  used  the  strength  of  the  current 
should  be  gradually  increased  ;  the  sponge  rheophores 
should  be  of  laro;e  size  and  thorou2:hlv  saturated  with 


256  TREATMENT  OF  SCIATICA. 

warm  salt  and  water.  Each  sitting  should  occupy  from 
10  to  15  minutes_,  and  during  the  application  the  rheo- 
phores  should  not  be  lifted  from  the  skin  ;  before  they 
are  removed  the  current  should  be  gradually  reduced  to 
zero.  Unless  this  precaution  be  taken,  more  or  less 
shock  will  be  caused  when  the  current  is  interrupted. 
There  are  three  modes  in  which  the  constant  current 
can  be  applied  : — 

1.  The  rheophore  connected  with  the  positive  pole  is 
applied  to  the  upper  part  of  the  sacrum  on  the  aflfected 
side,  while  the  other  rheophore  may  be  either  attached 
to  the  ankle  or  placed  in  a  tub  of  warm  salt  and  water 
in  which  the  patient  immerses  his  foot.  • 

2.  ^'^  Two  sponge  rheophores  are  applied  firmly  at  a 
distance  of  three  or  four  inches  apart  to  the  posterior 
and  upper  part  of  the  thigh_,  and,  that  distance  being 
preserved  between  them,  they  are  made  to  slide  slowly 
down,  following  the  track  of  the  nerve."  A  smaller 
number  of  cells  must  be  employed  than  in  the  pre- 
ceding method. 

3.  The  rheophore  connected  with  the  negative  pole 
is  applied  to  the  upper  part  of  the  sacrum,  and  the 
positive  rheophore  is  moved  over  the  course  of  the 
nerve,  stopping  for  a  minute  or  two  over  the  most 
painful    spots.     Dr.    Buzzard    states    that   the  second 


TREATMENT  OF  SCIATICA. 


257 


method  of  application  is  theoretically  the  best,  as  beins; 
specially  calculated  to  remove  the  irritability  of  the 
sciatic  nerve  near  its  origin.  The  sitting  should  be 
repeated  daily ;  the  use  of  electricity  does  not  preclude 
the  use  of  morphine  hypodermically. 

The  induction  current  is  far  less  serviceable  as  a 
general  rule,  but  it  may  be  tried  if  other  remedies  fail. 
It  is  most  suitable  for  those  cases  in  which  the  svm- 
ptoms  are  those  of  muscular  rheumatism.  The  electric 
brush  should  be  drawn  along  the  coarse  of  the  nerve  and 
its  branches  ;  slight  diminution  of  the  pain  is  usually  all 
that  can  be  expected.  At  a  later  period,  however,  after 
the  pains  have  subsided  and  the  limb  remains  weak  and 
stiff,  faradization  of  the  muscles  with  moistened  rheo- 
phores  is  often  very  efficacious.  The  use  of  this  form 
of  electricity  may  also  be  combined  with  the  hypodermic 
injections  of  morphine. 

Blisters  have  been  already  alluded  to  as  especially 
suitable  for  rheumatic  cases,  but  they  are  often  advisable 
in  the  absence  of  this  constitutional  disorder.  It  is  not 
by  any  means  necessary  to  make  a  large  raw  surface  ; 
flying  blisters  are  the  most  suitable,  and  they  may  be 
applied  along  the  course  of  the  nerve  and  its  branches, 
or  over  any  existing  tender  spot  in  the  spinal  column. 

17 


258  TREATMENT  OF  SCIATICA. 

Acupuncture  is  probably  but  little  practised  at  the 
present  time,  yet  it  would  appear  to  possess  a  certain 
amount  of  efficacy.  The  rationale  of  its  action  can 
only  be  guessed  at;  it  may  be  that  it  acts  as  a  counter- 
irritant. 

It  is  not  to  be  wondered  at  that  baths  of  all  kinds 
should  be  warmly  recommended  as  remedies  for  sciatica^ 
and  in  chronic  cases  they  are  sometimes  beneficial, 
inasmuch  as  they  help  to  remove  lingering  pain  and 
stiffness.  Ordinary  water,  heated  to  the  requisite 
temperature,  is  probably  as  useful  as  any  of  the  natural 
hot  springs.  The  constant  temperature  of  the  latter  is, 
however,  an  advantage.  When  baths  cannot  be  ob- 
tained, or  are  unsuitable  for  the  patient,  warm  applica- 
tions applied  to  the  limb  often  give  relief.  The  so-called 
Scotch  douche  is  reported  to  have  proved  efficacious  in 
several  severe  cases.  In  using  it  the  temperature  of  the 
water  is  gradually  increased  -to  the  maximum  that  the 
patient  can  bear,  and  a  cold  douche  is  then  substituted 
for  the  hot  one.  This  treatment  can  be  applied  twice  a 
day.  Hot  sand-baths  are  a  very  old  remedy,  but,  like 
douches,  they  are  to  be  found, only  in  special  estabhsh- 
ments  ;  they  would  appear  to  be  suitable  for  subacute 
and  chronic  cases.    The  same  remark  applies  to  massage. 


TREATMENT  OF  SCIATICA.  259 

from  which  great  benefit  may  be  expected  when  the 
limb  has  become  weakened  and  reduced  in  size  after  a 
severe  attack. 

In  a  few  cases  of  obstinate  sciatica  nerve-stretching 
has  been  practised  with  success.  All  other  remedies 
should,  of  course_,  be  tried  before  suggesting  an  opera- 
tion of  this  character. 


CHAPTER  IX. 

ARTICULAR  NEUROSES— NEURALGIA  OF  THE  JOINTS. 

Nature  and  Pathogeny  of  Neuralgia  of  the  Joints — Predisposing 
AND  Exciting  Causes — Symptoms — Cutaneous  HYPERiESTHESiA 
— Position  of  the  Limb — Joints  usually  Affected — Course  and 
Progress  of  Neuralgia  of  Joints — Diagnosis  —  Anaesthesia 
OFTEN  Necessary  —  Mental  Condition  of  the  Patient  — 
Results  of  Application  of  Bandages,  etc.  —  Exaggerated 
Patellar  Reflex  in  Hysterical  Contraction  of  the  Knee- 
Joints — Pain  in  Knee  an  Occasional  Symptom  of  Hip-Joint 
Disease — Treatment,  Constitutional  and  Local — Massage, 
Douches,  Baths,  etc. — Electricity — Use  of  the  Limb  to  be 
Recommended. 

This  affection  was  first  described  by  Sir  Benjamin 
Brodie  in  1822^  but  some  light  has  been  thrown  upon 
its  nature  bv  subsequent  investigations.  Neuralgia  of 
the  joints  is  a  painful  affection^  w  hich  has  its  seat  in  the 
sensory  nerves  supplying  the  articular  capsule^  the 
fibrous  lio-aments,  the  skin,  and  the  neis^hbourino;  tissues. 
The  pain  is  not  confined  to  a  single  nerve  and  its  dis- 
tribution, for  a  joint  is  supplied  by  branches  of  several 
nerv^es ;  the  hip-joint,  for  example,  is  supplied  by  the 
sciatic,  crural,  and  obturator  nerves,  while  branches 
of  the  external  and  internal  popliteal,  tibial,  crural,  and 


NEURALGIA   OF  THE  JOINTS.  261 

obturator  ramify  in  and  around  the  knee-joint.  A  rare 
form  of  neurosis  of  the  joints  is  due  to  vaso-motor 
disorder.  An  experiment  recently  made  explains,  to 
some  extent^  the  pathogeny  of  articular  neuralgia. 
After  a  lateral  section  of  the  spinal  cord,  involving 
Flechsig's  direct  cerebellar  paths  of  the  lateral  column_, 
the  joints  as  well  as  the  skin  of  the  injured  side  were 
observed  to  be  hyperaesthetic,  and  it  may  therefore  be 
that  changes  in  the  spinal  cord,  obviously  of  a  slight 
and  temporary  nature,  are  the  causes  of  neuralgia  of  the 
joints.  This  theory  is  supported  by  the  fact  that  various 
symptoms  of  spinal  disorder  are  frequent  in  hysterical 
women,  who  are  the  most  common  sufferers  from  these 
joint- affections. 

Neuralgia  of  the  joints  is  rare  in  male  subjects;  it  is 
almost  peculiar  to  women  of  a  nervous  temperament  and 
belonging  to  the  upper  classes.  Many  of  the  patients 
are  decidedly  hysterical,  and  are  the  subjects  of  various 
disorders  of  the  urinary  and  genital  organs.  Various 
conditions  of  anaemia  and  exhausting  diseases,  such  as 
typhoid,  are  predisposing  causes  of  these  joint-affections. 
The  majority  of  patients,  however,  attribute  their  suffer- 
ing to  injury  or  to  over-exertion  of  the  joint.  In  some 
cases  the  pain  is  due  to  irregular  distribution  of  pressure 


262      SYMPTOMS  OF  NFURALQIA  OF  THF  JOINTS. 

within  the  joints  such  as  may  be  caused  by  wearing 
shoes  with  high  heels,  and  in  other  instances  the 
neuralgia  is  the  remains  of  some  inflammatory  affection, 
due,  perhapSj  to  a  trifling  injury. 

Symptoms,  The  knee  or  the  hip-joint  is  almost 
always  affected,  and  the  principal  symptom  is  the  pain, 
invariably  described  as  very  severe ;  it  may  be  limited 
to  the  joint,  or  may  also  extend  from  it  in  various  direc- 
tions. Keeping  the  limb  at  rest  by  no  means  always 
diminishes  the  pain;  the  patients  sometimes  assert 
that  they  are  better  when  moving  about.  Exacerbations 
are  common,  and  occur  irregularly.  Sometimes  they 
are  provoked  by  excitement,  and  sometimes  by  attempts 
to  move  the  limb.  As  a  rule  they  are  most  troublesome 
in  the  latter  part  of  the  day.  It  very  rarely  happens 
that  the  night's  rest  is  disturbed  by  pain,  and  the 
complaint  is  thus  distinguished  from  inflammatory 
affections.  Pressure  upon  the  joint  and  the  surround- 
ing parts  usually  excites  great  pain.  The  spots  near 
the  hip  especially  sensitive  to  pressure  are  just 
behind  the  great  trochanter  and  below  Poupart's 
ligament,  while  the  inner  side  of  the  knee  is  the  most 
sensitive  part  of  that  articulation.  The  attempt  to 
take  up  a  fold  of  skin  between  the  fingers  is  also  liable 


SYMPTOMS  OF  NEURALGIA  OF  THE  JOINTS.      263 

to  cause  great  pain.  The  most  striking  feature  con- 
nected with  the  affection  is  the  contrast  presented  be- 
tween the  subjective  symptoms  and  the  absence  of  any 
tano:ible  or  visible  chang-es  in  the  ioint.  Anv  sweUino- 
that  may  exist 'is  generally  due  to  local  applications, 
fomentations,  etc.  In  most  cases  the  patients  assert 
that  the  limb  is  weak,  they  less  commonly  complain  of 
twitchings,  and  it  is  worthy  of  notice  that  the  limb  is 
usually  kept  in  an  extended  position,  whereas  it  is 
flexed  when  the  joint  is  inflamed.  There  are  sometimes 
evidences  of  vaso-motor  disorder,  such  as  redness  and 
increase  of  temperature,  and  an  eruption  resembling 
urticaria  has  occasionally  been  noticed. 

As  already  mentioned,  in  the  large  majority  of  cases 
the  knee  or  the  hip  is  the  joint  affected;  but  in- 
stances of  the  complaint  in  the  hand,  foot,  shoulder, 
and  elbow  have  been  placed  on  record.  In  the  vertebral 
column,  too,  articular  neuralgia  would  seem  to  occur, 
and  to  simulate  grave  affections.  As  a  general  rule  the 
pain  occurs  in  one  joint  only;  when  two  or  more  are 
implicated,  and  especially  if  they  be  symmetrically 
placed,  the  complaint  is  probably  of  a  central  origin. 

With  regard  to  its  course  and  progress,  neuralgia  of 
a  joint  usually  develops  gradually.     In  some  cases,  how- 


264     DIAGNOSIS  OF  NEURALGIA   OF  THE  JOINTS. 

ever_,  the  patients  assert  that  the  pain  came  on  suddenly 
after  shock,  excitement,  etc.  The  complaint  generally 
runs  a  very  tedious  course;  the  attention,  not  only  of 
the  patient,  but  also  of  her  friends,  is  apt  to  be  concen- 
trated upon  the  painful  joint,  with  the  result  of  magnify- 
ing the  suffering.  In  such  cases  it  will  often  be  noticed 
that  when  the  patient's  attention  is  in  any  way  diverted 
the  joint-troubles  are  forgotten.  The  pain,  indeed,  has 
been  known  to  disappear  altogether  after  some  sudden^ 
violent  emotion.  On  the  other  hand,  it  not  unfrequently 
happens  that  the  patient  keeps  her  bed  for  months 
or  years,  receiving,  it  may  be,  temporary  relief  from 
remedies,  but  never  exhibiting  any  real  improvement. 
The  tendency  is  for  the  limb  to  become  weaker,  and  the 
joint  more  stiff. 

Diagnosis.  The  diagnosis  of  nervous  affections  of 
joints  is  in  not  a  few  cases  a  very  difficult  task,  especi- 
ally in  the  early  stages,  and  whenever  there  is  any 
history  of  previous  injury,  however  slight  and  unim- 
portant. The  examination  should  be  very  carefully 
made,  and  it  is  often  useful  to  place  the  patient  under 
the  influence  of  an  anaesthetic.  If  a  joint  which  has 
for  some  time  been  rigidly  fixed  then  becomes  free,  there 
can  be  little  doubt    then  as  to  the   real   condition   of 


DIAGNOSIS  OF  NEUSALGIA   OF  THE  JOINTS.      265 

things  ;  but  it  is  generally  advisable  to  make  several  ex- 
aminations, and  it  is  often  necessary  to  keep  the  patient 
under  observation  for  some  time  before  arriving  at  a 
positive  conclusion.  There  are  generally  no  physical 
changes^  and  no  evidences  of  impaired  health.  The 
psychical  condition  of  the  patient  will  occasionally  help 
the  diagnosis,  and  if  treatment  be  adopted  it  will  gene- 
rally be  observed  that  remedies  which  would  relieve  a 
real  affection  of  a  joint  will  only  increase  the  symptoms 
in  a  neurotic  disorder.  It  has,  for  instance,  been  found 
that  the  application  of  bandages  to  a  knee-joint  affected 
with  neuralgia,  and  their  retention  for  several  weeks,  have 
served  only  to  make  matters  worse.  In  cases  of 
hysterical  contraction  of  the  knee-joint  the  state  of  the 
patellar  reflex  should  always  be  examined ;  it  will  gene- 
rally be  found  to  be  exaggerated.  In  a  case  recently 
under  my  notice,  that  of  a  married  woman,  aged  47, 
who  had  been  bedridden  for  a  year  with  hysterical  con- 
traction of  the  knee-joint  and  other  ailments,  the  knee 
jerked  out  immediately  the  patellar  reflex  was  tested. 
A  similar  result  was  obtained  in  another  case,  the 
patient  being  a  young  woman,  aged  26,  who  had  been 
bedridden  for  four  months.  It  must  not  be  forgotten 
that  in  young  subjects  obstinate   pain  in  the  knee  is 


266     TREATMENT  OF  NEURALGIA   OF  TEE  JOINTS. 

sometimes  the  first  symptom  of  disease  of  the  hip-joint, 
and  that  the  same  symptom  is  present  in  cases  of  genu 
valgum,  which  is  not  always  bi-lateral. 

Treatment.  Having  decided  that  the  case  is  one  of 
neuralgia  of  the  joint,  the  general  condition  of  the 
patient  has  first  to  be  considered.  If  there  be  evidences 
of  anaemia  or  debility  tonic  treatment  of  all  kinds  is 
indicated,  and  may  by  itself  cure  the  complaint.  Any 
disorder  of  the  digestive  or  genital  organs  must  be 
carefully  treated,  and  above  all  things  it  is  necessary  to 
divert  the  patient's  attention  from  the  joint,  and  to 
caution  the  friends  from  talking  seriously  about  it.  The 
patient  should  be  assured  that  she  will  get  quite  well  if 
she  will  only  cany  out  a  few  simple  injunctions.  The 
remedies  to  be  prescribed  are  massage,  carefully  con- 
ducted, douches  of  tepid  water,  active  and  passive  move- 
ments, frictions  and  baths,  especially  of  salt  water.  These 
remedies,  persevered  in  for  several  weeks,  may  prove 
sufficient,  but  if  not  there  are  others  which  may  be 
tried,  and  among  them  electricity  is  likely  to  be  the  most 
serviceable.  The  constant  current  is  the  best,  and  it  is 
especially  useful  whenever  any  points  can  be  detected 
which  are  decidedly  painful  on  pressure.  The  elec- 
trodes should   correspond  with  the  size  of  these  spots,. 


TREATMENT  OF  NEURALGIA   OF  THE  JOINTS.     267 

against  which  they  should  be  pressed^  the  strength  of 
the  current  being  gradually  increased  to  the  maximum 
that  the  patient  can  bear.  Before  withdrawing  the  elec- 
trodes the  strength  is  gradually  decreased.  In  cases  in 
which  the  neuralgia  of  the  joint  is  associated  with 
tenderness  over  one  or  more  vertebrae^  it  is  sometimes 
useful  to  apply  the  electrodes  to  the  latter.  If  the 
galvanic  current  fail  to  relieve^  faradism  may  be  tried, 
the  moist  electrodes  being  applied  as  before  to  the 
painful  spots.  The  wire  brush  applied  in  this  way  is 
likely  to  prove  serviceable  in  mild  cases.  Liniments, 
bandages,  poultices,  etc.,  are  always  to  be  avoided. 
The  patient  must  be  encouraged  to  use  the  limb  and 
to  walk  about,  -however  difficult  the  movement  may 
appear. 


CHAPTER   X. 

HEADACHE. 


Pain  in  Head  often  Symptomatic — Associated  with  Cerebral 
Hyperjemia,  Active  and  Passive — Causes  and  Consequences — 
Anemic  Headache — Symptoms — Headaches  in  Neurasthenia 
and  Nervous  Subjects  Generally — Sympathetic  Headache^ — 
Indigestion  as  a  Cause  of  Headache — Rheumatic  and  Gouty 
Headache — Headache  due  to  Intemperance — Headache  in 
Hysterical  Subjects — Pains  in  the  Head  due  to  Syphilis — 
Headache  due  to  Disorders  of  the  Refractive  Apparatus 
of  the  Eye — Diagnosis  of  Headache — Treatment  of  the 
Hyperjemic  and  Anemic  Forms — Remedies  for  Neurasthenic 
AND  Rheumatic  Cases — Empirical  Treatment. 


Pain  in  the  head  is  a  very  common  symptom  of  many 
disorders,  but  it  Ukewise  often  occurs  idiopathically_,  and 
constitutes  the  complaint  for  which  the  patient  seeks 
relief.  As  a  symptom_,  it  is  rarely  absent  in  febrile 
disorders ;  in  typhus  it  is  often  the  first  indication  of 
an  attack;  it  is  prominent  in  inflammatory  affections 
of  the  bones  of  the  cranium  and  their  coverings_,  as  in 
periostitis^  syphilitic  or  otherwise.  Headache  is  a 
marked  symptom  of  inflammation  within  the  cranium 
and  of  tumours  of  the  brain  and  its  membranes.  It  is 
sometimes  very  troublesome  in    severe    nasal   catarrh. 


FORMS  OF  SF  ABAC  HE.  269 

implicating  especially  the  frontal  sinuses  ;  and,  lastly, 
it  is  not  unfrcquent  in  affections  of  the  eye  and  ear.  A 
special  form  of  headache,  migraine  or  hemicrania,  will 
be  separately  described.  In  the  present  chapter  it  is 
proposed  to  consider  those  headaches  which,  not  con- 
nected with  acute  local  or  general  disorder,  are  due  to  a 
variety  of  causes  not  always  very  obvious,  and  com- 
paratively insignificant  when  contrasted  with  the  result 
they  produce. 

The  pain  is  sometimes  diffused  over  more  or  less  of 
the  head ;  it  may,  on  the  other  hand,  be  principally  felt 
in  the  forehead,  occiput,  vertex,  or  temples.  Sometimes 
it  is  localized  in  a  very  small  area,  as  in  clavus  hystericus. 
The  character  of  the  pain  varies  with  the  condition 
with  which  it  is  associated.  Thus,  when  there  is 
active  hypersemia,  it  is  described  as  throhhing,  and 
a  similar  sensation  is  experienced  in  anaemia  when 
the  vessels  are  dilated.  In  passive  hyperaemia,  the 
sensation  is  that  of  pressure;  in  rheumatic  cases  the 
pain  is  of  a  pricking  or  tearing  character.  In  degree  of 
severity  the  pain  of  headache  varies  greatly ;  it  may  be 
only  so  slight  as  to  be  scarcely  regarded,  or  so  severe  as 
to  be  described  as  unbearable.  In  idiopathic  cases  the 
pain  is   wont   to    occur  periodically;  it  is  rarely  con- 


27©  FORMS  OF  SFABACSF. 

tinaous,  except  in  cases  of  anaemia.  Whenever  it 
comes  on  at  definite  intervals,  and  at  the  same  hour, 
it  may  generally  be  regarded  as  of  a  neuralgic  character. 
For  purposes  of  consideration  headaches  may  be  divided 
into  classes,  according  as  they  are  associated  v^^ith 
vascular  or  nervous  symptoms.  The  former  may  be 
either  those  of  increased  or  of  diminished  blood-supply, 
and  this  first  category  may  again  be  subdivided  into 
those  in  which  the  hypersemia  is  active  and  those  in 
which  it  is  passive. 

In  headache  due  to  active  hyperaemia  of  the  cerebral 
vessels  the  condition  is  manifested  by  the  state  of  face 
and  eyes,  which  are  red  and  hot.  The  temporal  arteries 
are  prominent  and  pulsate  freely  -,  the  carotids  are  full 
and  tense  ;  the  pain  is  increased  on  stooping  and  lower- 
ing the  head,  and  relieved  by  the  opposite  postures ;  the 
patient  complains  of  giddiness,  noises  in  the  ears,  and 
black  specks  and  flashes  of  light  before  the  eyes.  This 
condition  is  not  unfrequently  observed  after  indulgence 
in  alcohol  and  as  a  result  of  excitement  of  various  kinds. 
When  oft  repeated,  the  enlargement  of  the  vessels  is 
apt  to  become  permanent,  as  a  result  of  paralysis  of  the 
vaso-constrictor  nerves.  The  headache  then  persists, 
becoming  more  severe  under  any  form  of  excitement. 


FORMS  OF  HIE  AD  A  CHE. 


271 


This  kind  of  headache  is  not  anfrequent  as  the  result 
of  excessive  brain-work,  and  the  symptoms  associated 
with  it  may  closely  resemble  those  of  chronic  and  severe 
cerebral  congestion.  If  neglected,  the  consequences 
are  apt  to  become  very  serious  j  sleeplessness  is  always 
present,  and  its  effect  is  to  exaggerate  all  the  symptoms. 
Vomiting,  attacks  resembling  apoplexy  and  attended 
by  transient  loss  of  speech,  are  not  uncommon,  and  the 
complaint  at  this  stage  proves  very  intractable. 

Headache,  associated  with  passive  hyperaemia,  is  a 
common  symptom  of  diseases  in  which  the  escape  of 
blood  from  the  veins  of  the  skull  is  impeded.  Hence  it 
is  frequently  met  with  in  diseases  of  the  heart,  and  in 
cases  in  which  cervical  tumours,  glandular  or  otherwise^ 
press  upon  the  veins  of  the  neck. 

Headache  is  very  common  in  conditions  of  anaemia, 
and  great  care  is  necessary  lest  any  mistake  should  be 
made  in  the  diagnosis,  and,  consequently,  in  the  treat- 
ment. In  these  patients,  although  the  cheeks  may  be 
flushed,  the  conjunctivae  and  gums  are  pale,  a  venous 
hum  can  be  heard  in  the  neck,  and  the  headache  is 
diminished  when  the  patient  is  m  the  recumbent  posi- 
tion. The  sensation  in  the  head  is  described  as  if  the 
skull  were  forcibly   compressed.      There  is  likewise  a 


272  FORMS  OF  SF  ABAC  HE. 

feeling  of  throbbing  and  beating  within  the  cranium^  and 
giddiness  and  humming  in  the  ears  are  often  very 
troublesome.  Marked  cases  of  this  kind  are  often  seen 
in  women,  as  a  result  of  prolonged  lactation. 

Headaches  in  which  nervous  symptoms  predominate 
are  also  very  common^  and  are  seen  especially  in  the 
subjects  of  neurasthenia.  These  form  a  large  class  at 
the  present  day^  and  include  brain-workers  of  all  kinds^ 
men  of  business,  speculators^  and  others  whose  nervous 
system  is  continually  under  a  high  degree  of  tension. 
The  complaint  is  also  common  in  women  as  a  result  of 
anxiety  and  mental  and  bodily  strain.  The  prominent 
symptom  is  that  of  weight  or  pressure  felt  generally  at 
the  vertex,  and  with  this  other  symptoms  of  neuras- 
thenia^  as  described  in  the  chapter  devoted  to  that  sub- 
ject, are  always  associated.  In  some  cases  there  is 
more  or  less  hypersemia,  generally  unilateral,  of  the 
cerebral  vessels,  and  such  patients  often  suffer  from 
sleeplessness  and  various  forms  of  indigestion.  Mental 
disorder  is  a  marked  feature  in  these  cases ;  listlessness 
and  aversion  to  work  of  any  kind  alternate  with  fits  of 
irritability  or  depression,  which  latter  sometimes  amounts 
to  melancholia. 

Some  forms  of  headache  may  justly  be  regarded  as 


FORMS  OF  HEAD  AC  RE.  273 

sympathetic  in  character,  the  most  marked  of  these 
being  that  which  not  unfrequently  accompanies  acute 
attacks  of  indigestion.  The  connection  between  the 
headache  and  the  state  of  the  stomach  is  shown  bv  the 
fact  that  the  former  is  greatly  reheved,  or  perhaps  com- 
pletely subsides,  when  vomiting  takes  place.  Headaches 
o'f  this  class  are  often  associated  wath  excess  of  acid  in 
the  stomach,  presumably  due  to  fermentation.  In  these 
cases  the  exhibition  of  a  full  dose  of  sodium  carbonate 
sometimes  acts  like  a  charm.  Other  forms  of  headache 
belonging  to  this  category  are  those  which  occur  in 
women  suffering  from  uterine  disorders. 

Rheumatic  and  gouty  subjects  are  prone  to  suffer 
from  headache.  In  the  former,  attacks  frequently  come 
on  after  exposure  to  cold  draughts ;  the  pain  is  situated 
in  the  scalp^  which  is  likewise  tender  on  pressure.  It 
is  always  relieved  by  warmth.  In  gouty  subjects,  the 
headache  takes  the  form  either  of  mig-raine,  which  is 
very  common,  or  of  sharp  explosions  of  lightning-like 
pains  over  the  parietal  bones,  occurring  in  quick  succes- 
sion, but  unaccompanied  by  tenderness  on  pressure. 
Such  attacks  are  sometimes  to  be  traced'  to  indulgence 
in  wine  and  animal  food  ;  they  are  relieved  by  purgatives 
and  alkalies.     In  other  patients  of  this  class  it  is  found 

18 


274 


FORMS  OF  HFABACHF. 


that  the  articular  attacks,,  at  one  time  very  frequent, 
either  cease  or  become  less  marked,  but  are  succeeded 
by  headache,  sleeplessness,  vertigo,  dizziness,  and  other 
symptoms  of  nervous  disorder.  The  symptoms  in 
these  cases  resemble  those  produced  by  the  action  of 
certain  poisons  which  require  a  brief  notice. 

Headache  due  to  indulgence  in  alcoholic  liquors  has 
been  already  mentioned,  and  in  chronic  cases  results,  in 
some  degree  at  least,  from  the  action  of  the  poison 
upon  the  stomach  and  liver.  A  small  dose  of  opium 
affects  some  persons  in  a  similar  manner;  and  to  the 
same  category  belong  those  forms  of  severe  headache 
which  are  associated  with  uraemia,  chronic  lead-poison- 
ing, etc. 

The  headache  which  is  so  prominent  a  feature  in 
many  hysterical  subjects  has  been  described  in  the 
chapter  on  hysteria. 

One  form  of  headache,  viz.,  that  connected  with 
syphilis,  deserves  a  brief  notice,  if  only  because  its 
nature  is  apt  to  be  overlooked,  and  the  treatment 
correspondingly  misdirected.  Pain  in  the  head  often 
accompanies  an  outbreak  of  secondary  symptoms,  and 
is  wont  to  persist  after  the  fever  has  subsided  and  the 
eruption  is  fully  out.     The  seat  of  the  pain  is  usually 


FORMS  OF  HFADACRF.  275 

over  the  vertex^  but  sometimes  at  the  occiput  and  in  the 
base  of  the  skull.  The  pain  is  more  or  less  continuous, 
but  exacerbates  at  night;  it  is  sometimes  very  violent, 
and  associated  with  great  mental  excitement,  or  even 
delirium.  It  may  be  due  to  periosteal  .  inflamma- 
tion or  intracranial  mischief,  which  latter  sometimes 
supervenes  in  the  early  stages  of  syphilis,  i.e..  within 
the  first  or  second  year.  When  called  upon  to  treat 
acute  headache  in  young  male  adults,  the  possibility  of 
syphilis  should  always  be  kept  in  mind.  The  presence 
of  enlarged  glands  in  the  neck  and  groins  will  establish 
the  diagnosis.  Headache  due  to  syphilis  may  occur 
many  years  after  the  primary  disorder.  I  occasionally 
treat  a  case  of  this  nature.  The  patient  suffers  at 
intervals  from  severe  headache  and  neuralgic  pains, 
which  are  always  relieved  by  large  doses  of  the 
iodides. 

There  is,  lastly,  one  important  form  of  headache 
which  must  not  be  passed  over,  though  hitherto  but 
little  attention  has  been  paid  to  it.  In  not  a  few  cases 
headache  of  a  more  or  less  severe  character  is  due  to 
disorders  of  the  refractive  apparatus  of  the  eye.  As 
might  be  expected,  this  form  resists  all  ordinary  routine 
treatment;  but  yields  at  once  when  the  proper  measures 


276        st:adacji:e  fbom  visual  disoebehs. 

are  adopted.  The  attention  of  the  profession  was  par- 
ticularly directed  to  this  form  of  headache  some  years 
ago  by  Mr.  Briidenell  Carter^  who  met  with  a  case  in 
which  a  wrong  diagnosis  had  caused  much  anxiety  and 
a  useless  and  expensive  course  of  treatment.  A  young 
man  studying  at  Oxford  was  attacked  by  severe  head- 
symptoms^  which  were  attributed  to  disease  of  the 
brain.  A  sea-voyage  was  ordered  and  taken,  but  caused 
no  change  in  the  symptoms.  On  examining  the  eyes 
with  the  ophthalmoscope,  Mr.  Carter  found  the  patient 
to  be  myopic;  glasses  were  ordered^  and  a  few  weeks 
afterwards  all  the  head-symptoms  had  disappeared. 
Two  years  afterwards  the  condition  was  reported  as 
quite  satisfactory.  Several  cases  of  a  like  nature  have 
been  lately  reported,*  such  conditions  as  simple  and 
^compound  hypermetropic  and  myopic  astigmatism 
being  discovered  on  examination.  Besides  the  attacks 
of  headache,  such  patients  often  complain  of  giddiness, 
faintness,  indigestion  in  various  forms,  languor,  sleep- 
lessness,   and    debility,    all    of    which    symptoms    are 


*  See  paper  by  Mr.  T.  H.  Bickerton,  on  "  Headache  due  to  Errors  of 
the  Refractive  Media  of  the  Eye,"  Lancet,  August  13,  1887.  See  also 
Dr.  Stevens'  work  on  "  Functional  Nervous  Affections,"  p.  35. 


DIAaNOSIS  OF  HEADACHE.  277 

relieved  or  cured  by  the  use  of  suitable  glasses.  There 
can  be  no  doubt  as  to  the  part  which  errors  of  refraction 
play  in  the  causation  of  many  cases  of  headache. 

The  account  just  given  of  the  various  forms  of  head- 
,  ache  will  sufficiently  indicate  the  great  variety  of  con- 
ditions under  which  the  affection  may  arise.  Neuralgia' 
affectins:  the  head  and  mi2;raine  are  to  be  distinp:uished 
from  headache  in  general ;  in  the  former  the  pain 
follows  the  course  of  certain  nerves,  branches  of  the 
fifth  or  the  occipital;  in  migraine  the  pain  is  one  of  a 
series  of  symptoms.  In  all  cases  of  headache  every 
attempt  should  be  made  to  ascertain  the  cause"  of  the 
pain  and  the  conditions  with  which  it  is  associated. 
Attention  should,  therefore,  be  paid  to  the  head  itself, 
the  eyes  and  nose,  the  organs  of  circulation  and  diges- 
tion, the  state  of  the  urine,  etc.  The  history  of  the 
attack  should  likewise  be  inquired  into;  the  seat  of  the 
pain,  the  frequency  of  its  occurrence;  the  presence  or 
absence  of  febrile  symptoms  and  of  concomitant  dis- 
order in  other  parts  are  the  main  points  to  be  attended 
to.  In  all  cases  of  severe  headache,  and  especially  in 
those  for  which  it  is  difficult  to  assign  an  obvious  cause, 
the  ophthalmoscope  should  be  used,  and  at  the  same 
time  the  urine  should  be  carefully  examined  for  albumen 


2  78  TREA  TMI:NT  OF  SUA  DA  CHE. 

and  casts  of  the  tubes.  Severe  and  persistent  headache 
is  a  frequent  symptom  of  cerebral  tumours,  and  is  not 
uncommon  in  advanced  renal  disease.  In  the  former, 
optic  neuritis  is  almost  invariably  present  in  one  or 
other  of  its  stages;  in  Bright's  disease,  evidences  of 
albuminuric  retinitis,  such  as  haemorrhages,  diffuse 
opacity  and  swelling  of  the  retina,  small  whitish  spots 
of  degeneration,  inflammation,  and  atrophy  of  the  retina 
and  nerve,  are  discoverable  in  a  large  proportion  of 
cases. 

Treatment.  Every  case  of  headache  requires  to  be 
made  a  separate  study  in  order  that  the  treatment  may 
be  properly  directed,  In  chronic  cases  with  evidences 
of  cerebral  hypersemia,  the  diet  should  be  restricted ; 
stimulants  should  be  forbidden,  and  tea  and  coffee  taken 
in  great  moderation.  In  very  severe  attacks,  a  few 
leeches  behind  the  ears  or  to  the  temples  will  serve  to 
relieve  the  pain ;  and  in  chronic  and  less  severe 
cases  a  blister  at  the  back  of  the  neck,  or  even  a  mustard 
plaster,  will  be  found  efficacious.  Cold  applications  to 
the  head  are  always  grateful  to  the  patient  j^  cold  affusion 
may  be  practised,  or  an  indiarubber  bag  filled,  with  iced 
water  may  be  placed  upon  the  head.  Saline  purgatives 
are  usually  indicated,  and   sometimes   it  is  necessary  to 


TREATMENT  OF  HEADACHE.  279 

aid  their  effect  by  a  preliminary  dose  of  calomel  or  com- 
pound colocynth  pill.  Various  mineral  waters  are 
suitable  for  these  cases^  and  especially  those  of  Carlsbad, 
Marienbad,  Friederichshall_,  Hunyadi  Janos,  and  Rubi- 
nat  Condal.  For  gouty  subjects  in  whom  the  headache 
is  apt  to  be  accompanied  by  symptoms  of  gastric  catarrh, 
fermentation  and  acidity,  the  Carlsbad  and  Marienbad 
waters  are  especially  suitable.  The  bromides  may  be 
required  to  relieve  pain  and  to  cahn  excitement,  but 
their  use  should  not  be  too  long  continued.  Galvanism 
applied  to  the  sympathetic  nerve  in  the  neck  is  some- 
times useful.  For  this  purpose  the  cathode  should  be 
applied  to  the  inner  border  of  the  sterno-mastoid  muscle, 
the  anode  being  held  in  the  hand ;  the  circuit  can  be 
interrupted  by  alternately  removing  and  replacing  the 
anode.  When  the  active  symptoms  have  subsided,  and 
in  slight  cases,  tonics  are  generally  suitable;  the  nitro- 
muriatic  acid,  nux  vomica,  and  henbane,  form  an  appro- 
priate combination. 

In  opposite  conditions  of  the  system,  viz.,  those  con- 
nected with  anaemia,  tonics  are  indicated,  and  especially 
the  various  preparations  of  iron  and  quinine.  Arsenic 
and  strychnine  are  also  sometimes  suitable  for  these 
cases. 


28o  TEUATMIJNT  OF  SBABACHE. 

Headaches  occurring  in  cases  of  neurasthenia  are  often 
very  difficult  to  treat.  Rest  is  one  main  element  in  the 
treatment,  and  change  of  air  to  a  suitable  locality  will 
often  do  more  good  than  medicines.  Anaemia  must  be 
dealt  with  as  above  indicated.  In  some  cases  a  com- 
bination of  quinine  with  hydrobroraic  acid  proves  very 
serviceable.  Bromide  of  potassium  is  useful  to  procure 
sleep;,  and  morphine  may  be  used  hypodermically  for  the 
same  purpose.  Moderate  exercise^  plain  nutritious  diet, 
with  a  few  glasses  of  good  wine  (Burgundy  is  one  of  the 
best),  and  tepid  baths  will  do  much  to  improve  the 
general  health.  A  course  of  strychnine  is  likely  to  be 
beneficial. 

For  rheumatic  headache,  alkalies  and  warm  applica- 
tions are  indicated,  and  a  few  doses  of  iodide  of  potas- 
sium will  often  cause  the  pain  to  subside.  This  last- 
named  drug  is  especially  indicated  in  syphilitic  cases, 
and  if  the  pain  does  not  yield  a  course  of  mercury  is 
always  desirable. 

The  treatment  of  headache  due  to  sympathy  with 
other  organs  is  that  of  the  original  affection.  That  of 
headache  connected  with  errors  of  refraction  is  simply 
the  use  of  appropriate  spectacles. 

In  cases  in  which,  after  thorough   investigation,  the 


tri:atmjEnt  of  sfadacsf.  281 

cause  remains  obscure,  and  the  indications  for  treatment 
are  therefore  doubtful,  such  remedies  as  caffeine^  guarana^ 
the  bromides,  butyl-chloral,  and  gelsemium,  may  be  tried. 
If  periodicity  be  a  feature  of  the  attacks,  and  particularly 
if  there  be  any  history  of  exposure  to  malaria,  quinine 
should  be  given  in  full  doses.  Anodynes  applied  locally 
will  also  help  to  relieve  the  pain.  The  most  suitable 
for  use  are  the  liniments  of  opium,  aconite,  and  bella- 
donna, either  separately  or  mixed,  and  to  any  of  these  a 
little  chloroform  liniment  may  be  added  with  advantage. 


CHAPTER   XL 

HEMICRANIA.— MIGRAINE.— MEGRIM. 


Frequency  of  Hemicrania — Its  prominent  features — Premonitory 
Symptoms — Symptoms  of  the  Attack — Phenomena  '  indica- 
tive OF  Vaso-motor  Disturbance — Two  Forms — Disorders 
of  Vision — Periodicity  of  Migraine — Length  of  Paroxysms 
— Causes  of  Migraine — Sex,  Age,  Hereditary  Tendency, 
Gouty  Predisposition — Exciting  Causes — Anxiety,  Over- 
exertion, Impressions  on  Certain  Nerves  of  Special  Sense, 
Derangement  of  Stomach,  Relation  of  Gastric  Symptoms, 
to  Migraine,  Insomnia — Pathogeny  of  Migraine — The  Spastic 
form — Pain  due  to  Spasm  of  the  Muscular  Coat  of  the 
Vessels — Fluctuations  in  the  Supply  of  Arterial  Blood  as 
Causes  of  Irritation — Dr.  Liveing's  Theory  of  the  Irregular 
Accumulation  and  Discharge  of  Nerve  Force — Migraine 
thought  by  some  to  be  only  a  Variety  of  Trigeminal  Neu- 
ralgia— Diagnosis — Prognosis  —  Treatment — A  Course  of 
Quinine — Aperients — The  Iodides  with   the   Alkaline   Car-. 

BONATES  FOR  GoUTY    SUBJECTS — STRYCHNINE,    ArSENIC,  OxIDE    OF 

Zinc,  and  Nitrate  of  Silver — Attention  to  Diet  and  Habits — 
Question  with  regard  to  Stimulants,  Sleep,  and  Exercise — 
Change  of  Air  and  Scene — Precautionary  Measures  when  a 
Paroxysm  is  Threatening — Rest,  Darkness,  and  Warmth — 
Stimulants,  Nux  Vomica,  Sodium  Bicarbonate — Antipyrin — 
Treatment  during  the  Attack — Darkness  and  Quiet,  Cold 
to  the  Head,  and  Warmth  to  the  Feet — Amyl  Nitrite — 
Ergot — Cannabis  Indica — Chloral — Morphine — Caffeine  and 
Guar  AN  A — Galvanism. 


This  form  of  headache   is  very  common,  and   causes 
more  suffering  and  incapacity  for  work  than  could  well  be 


MIGRAINE.  28.^ 

imagined  by  those  who  have  had  no  personal  experience 
of  the  complaint.  There  are,  moreover,  many  obscure 
points  connected  with  its  pathogeny,  and  it  is  often  very 
intractable ;  for  these  and  other  reasons  this  affection  is 
worthy  of  minute  consideration. 

Hemicrania  is  characterized  by  paroxysmal  attacks  of 
pain,  on  one  or  other  side  of  the  head,  of  apparently 
spontaneous  origin,  and  very  generally  accompanied  by 
vaso-motor  disturbances,  upon  which  the  principal 
symptom  seems  to  depend.  The  left  side  is  more 
frequently  affected  than  the  right,  but  the  pain  is  not 
restricted  to  either  side  in  any  given  case,  sometimes 
one  side  being  affected,  sometimes  the  other.  Various 
modifications  are  observed  in  this  respect ;  for  instance, 
the  attacks  may  come  on  in  the  left  side  for  months  or 
even  -years,  and  afterwards  affect  the  right  half  of  the 
head  for  a  time  and  then  become  irregular.  Even  when 
this  alternation  has  become  established  the  pain  is 
usually  more  severe  on  one  side  than  on  the  other. 
In  some  instances  in  which  the  pain  is  truly  unilateral 
there  is  some  amount  of  uneasiness  felt  on  the  other 
side. 

As  a  general  rule  attacks  of  migraine  are  preceded  by 
certain  prodromal  symptoms,  the  nature  and   duration 


284  MIGRAINE. 


of  which  vary  In  different  cases  and  in  different  attacks. 
For  a  period  varying  from  half-an-hour  to  perhaps  three 
or  four  hours  before  the  pain  comes  on  the  patient 
complains  of  discomfort  or  a  feeling  of  pressure  in  the 
head,  of  fatigue  and  disinclination  towards  exertion^  of 
depression  of  spirits_,  etc.  In  some  cases  there  is 
incessant  yawning,  frequent  sneezing,  and  a  feeling  of 
chilliness;  nausea  and  vomiting  are  also  sometimes 
present.  Flashes  of  light  before  the  eyes^  black  spots, 
indistinct  vision  or  hemiopsia,  and  noises  in  the  ears 
are  other  subjective  phenomena  which  are  often  noticed. 
Sometimes  the  patient  finds  the  pain  present  on  waking, 
as  in  a  case  which  I  attended  in  consultation  with  Sir 
W.  Jenner  j  sometimes  the  attacks  occur  in  the  even- 
ing, after  a  day  of  more  or  less  uneasiness.  The  pain 
never  comes  on  suddenly  and  without  warning,  as  in 
attacks  of  true  neuralgia ;  it  is  not  uniformly  diffused 
over  the  head,  but  is  felt  acutely  in  one  spot,  generally 
over  the  inner  angle  of  the  eye.  It  may,  however, 
spread  thence  to  the  frontal  region  in  general,  and  in 
some  attacks  the  side  of  the  head  is  more  or  less  painful. 
The  character  of  the  pain  is  variously  described  by 
patients,  and  probably  varies  in  different  cases  and  in 
different  attacks  ;  it  is   therefore  spoken   of  as   heavy, 


SYMPTOMS  OF  MIGRAINE.  285 

dull,  boring,  piercing,  splitting,  etc.  Some  patients 
complain  of  a  feeling  of  tension,  as  if  the  head  would 
burst.  Certain  of  the  prodromal  symptoms  remain  and 
even  become  aggravated  during  the  attacks ;  thus 
nausea  and  vomiting  are  often  very  distressing,  and 
some  of  the  ocular  and  auditory  symptoms  are  prone  to 
increase. 

In  a  large  proportion  of  cases  of  migraine  the 
paroxysms  are  attended  by  circulatory  phenomena  in- 
dicative of  vaso-motor  disturbance,  and  these  symptoms 
occur  in  two  principal  forms.  In  the  first  of  these 
during  the  attack  the  painful  side  is  pale  and  shrunken, 
the  pupil  dilated,  the  temporal  artery  hard  and  tense, 
and  the  ear  is  pale  and  cold.  The  pain  is  increased  by 
coughing  and  stooping,  and  at  each  pulsation  of  the 
temporal  artery.  Compression  of  the  carotid  tends 
rather  to  increase  the  pain  than  otherwise.  There  is 
often  an  augmented  flow  of  thick  saliva.  After  an 
interval,  which  varies  much  in  diflferent  cases,  an 
opposite  condition  becomes  established.  The  face 
becomes  red  and  full,  the  ear  is  hot,  the  eye  is  injected, 
and  the  pupil  often  becomes  contracted.  Other  sym- 
ptoms which  are  liable  to  occur  are  palpitation  of  the 
heart  with  increased  frequency  of  the  pulse,  sensation 


286  SYMPTOMS  OF  MiaRAINF. 

of  heat  over  the  body,  yomiting,  and  secretion  of  limpid 
urine.  The  vomiting  and  retching  are  apt  to  be 
peculiarly  distressing  in  young  subjects  ;  as  age  ad- 
vances these  symptoms  generally  become  less  prominent. 
At  the  close  of  some  attacks  diarrhoea  occasionally  sets 
in.  I  am  now  attending  a  lady,  aged  34,  who  always 
has  diarrhoea  after  the  attacks. 

In  the  second  form,  when  the  attack  is  at  its  height, 
the  face  and  ear  on  the  affected  side  are  hot,  red,  and 
swollen,  the  eye  injected,  the  pupil  contracted,  and  the 
lachrymal  secretion  profuse.  Sometimes  the  upper  lid 
feels  stiff  and  difficult  to  raise;  the  temporal  artery  and 
sometimes  the  carotid  are  dilated  and  pulsate  freely. 
The  pain  is  diminished  by  pressure  over  the  carotid. 
The  pulse  is  less  frequent  than  normal,  and  the  radial 
artery  feels  small  and  contracted ;  but  these  are  not 
constant  phenomena.  In  some  few  cases  ophthalmo- 
scopic examination  reveals  dilatation  of  the  central 
vessels  of  the  retina,  tortuosity  of  the  veins,  dilatation 
of  the  choroidal  vessels,  and  a  dusky  appearance  of  the 
back  of  the  eye.  There  is  nothing  characteristic  about 
these  appearances,  for  in  some  cases  ophthalmoscopic 
examination  has  yielded  negative  results.  As  the 
attack    passes     off    the    above-mentioned    symptoms 


SYMPTOMS  OF  MIGRAINJE.  287 

gradually  subside.  One  curious  feature  in  connection 
with  these  phenomena  is  that  they  sometimes  occur 
in  alternate  attacks  in  the  same  patient.  Moreover^ 
certain  symptoms  of  the  one  form  are  sometimes 
associated  with  those  of  the  other  type.  In  yet  another 
class  of  cases  of  migraine  the  vaso-motor  symptoms 
are  either  altogether  absent^  or  so  slight  as  to  be  scarcely 
observable,  and  whatever  may  be  the  type  of  the  dis- 
order^  the  changes  in  the  size  of  the  pupil  are  by  no 
means  constant. 

The  disorders  of  sight  require  a  more  detailed  notice, 
inasmuch  as  they  constitute  a  marked  feature  of  a  cer- 
tain proportion  of  cases.  They  present  two  forms,  viz., 
partial  or  complete  loss,  or  indistinctness,  of  vision  in  a 
portion  of  the  visual  field,  and  certain  spectral  appear- 
ances. The  extent  to  which  vision  is  interfered  with 
varies  in  different  cases.  If  the  obliteration  be  centric 
more  or  less  of  the  page  of  a  book  will  be  unnoticed 
when  the  patient  attempts  to  read.  If  it  be  eccentric, 
that  is,  not  corresponding  with  the  macula  lutea,  several 
words  or  letters  will  be  found  to  disappear.  Some 
patients  describe  a  general  dimness  of  vision,  coming  on 
in  paroxysms,  with  intervals  in  which  the  sight  is  com- 
paratively unaffected.     The  spectral  appearances  are  less 


288  SYMPTOMS  OF  MIGRAINE. 

frequently  noticed  ;  flashes  of  light  are  perhaps  the  most 
common.  Some  patients  describe  a  kind  of  ghmmer- 
ing,  as  though  surrounding  objects  were  in  a  state  of 
oscillation;  others  have  noticed  in  addition  luminous 
lines  forming  zigzags  and  circles,  surrounding  either  the 
objects  looked  at  or  the  darkened  portions  of  the  visual 
field.  The  disorders  of  vision^  whatever  form  they  may 
assume,  rarely  last  for  more  than  an  hour  unless  the 
patient  happens  to  be  travelling  by  road  or  rail  when  the 
attack  comes  on.  In  that  case  the  visual  troubles  are 
liable  to  become  more  severe,  and  they  may  continue 
until  the  journey  is  completed. 

Periodicity  is  a  characteristic  of  migraine,  and  is  well- 
marked  in  not  a  few  cases,  the  attacks  recurring  with 
extraordinary  regularity  at  weekly,  fortnightly,  or  other 
definite  intervals.  During  such  intervals  the  patients 
are  completely  free  from  pain,  but  many  of  them  find 
that  an  attack  is  liable  at  any  time  to  supervene  as  a 
result  of  such  causes  as  over-fatigue,  excitement,  anxiety, 
exposure  to  cold,  and  indigestion.  The  paroxysms  vary 
in  length  in  different  cases,  but  they  generally  subside 
within  twenty-four  hours.  Some  patients  are  fortunate 
enough  to  escape  with  only  a  few  hours'  suffering.  If 
the  attack  commences  at  noon,  or  at  any  time  after- 


CA  USES  OF  MIGRAINE.  289 

wardsj  it  generally  reaches  its  acme  before  bed-time  ; 
the  patient  then  is  apt  to  fall  into  a  heavy  sleep^  from 
which  he  awakes,  whether  in  the  night  or  early  morning, 
free  from  pain.  There  are,  however,  exceptions  to  this 
ruJe,  for  in  a  small  proportion  of  sufferers  the  attacks 
last  for  several  days,  the  pain  becoming  remittent,  but 
not  subsiding  altogether.  This  form  of  migraine  is 
naturally  a  very  distressing  one;  while  the  attack  lasts 
all  kinds  of  exertion  are  utterly  distasteful,  if  not  impos- 
sible. Those  who,  under  such  circumstances,  have  to 
attend  to  the  slightest  duties  are  much  to  be  pitied. 
.  The  causes  of  migraine  are  of  a  very  varied  character 
and  will  require  to  be  discussed  at  some  length.  The 
effect  of  certain  factors  as  predisposing  causes  is  beyond 
a  doubt;  and  among  these  the  chief  are  sex,  age,  and 
hereditary  influence.  The  female  sex  furnishes  the 
largest  contingent  of  sufferers,  and  in  this  respect, 
migraine  is  comparable  with  tic  douloureux.  The  first 
appearance  of  the  attacks  often  coincides  with  that  of 
the  menstrual  process,  and  they  are  wont  to  cease  after 
the  menopause;  their  severity  and  frequency  are  in- 
creased by  menstrual  irregularities.  With  regard  to 
age,  the  attacks  generally  appear  before  adult  life  is 
reached ;   it  has  indeed  been  stated  that  they  rarely,  if 

19 


290  CAUSES  OF  3IIGRAINJE. 

ever^  occur  for  the  first  time  in  persons  over  twenty- 
five  years  of  age^  but  this  statement  is  far  from  being 
correct.  In  the  large  majority  of  cases,  migraine  first 
shows  itself  at  the  period  of  puberty  ;  but  where  there 
is  decided  hereditary  predisposition  the  attacks  may 
come  on  at  a  much  earlier  age.  In  these  latter  cases^ 
the  time  of  their  appearance  probably  depends  upon  the 
manner  in  which  the  child  is  brought  up.  A  too  early 
or  too  close  application  to  studies  is  beyond  all  doubt  a 
potent  factor  in  the  early  development,  of  the  com- 
plaint. 

A  decided  hereditary  tendency  can  often  be  shown  to 
exist  in  cases  of  migraine^  the  occurrence  of  the  com- 
plaint being  traceable  through  several  generations.  It 
is  moreover  a  fact  of  considerable  interest  that  the  com- 
plaint is  apt  to  occur  in  children  whose  progenitors  have 
suffered  from  other  forms  of  nervous  disorders,  e.g., 
epilepsy,  hysteria,  neuralgia,  and  various  mental  de- 
rangements. When  the  hereditary  predisposition  to 
nervous  affections  is  very  strongly  marked  in  one  or 
both  parents,  it  is  sometimes  noticed  that  one  child 
may  suffer  from  migraine,  while  others  are  the  subjects 
of  epilepsy,  hysteria,  or  neuralgia.  A  gouty  family 
history   is  a  predisposing  cause  of  migraine.     In  my 


CAUSES  OF  MIGRAINE.  291 

work  on  Gout*  I  have  drawn  attention  to  the  frequent 
coincidence  of  nervous  affections  with  the  presence  of 
the  gouty  diathesis.  In  some  famiHes  acute  gout 
shows  itself  in  the  male  members,  while  the  females 
suffer  from  neuralgia  in  various  forms,  and  especially 
from  migraine.  These  nervous  disorders  likewise  are 
wont  to  alternate  with  acute  attacks  of  gout,  and  some- 
times take  the  place  of  the  latter.  Dr.  Liveing  thinks 
that  migraine,  whatever  form  it  may  assume,  is  very 
frequently  connected  with  the  gouty  diathesis,  and  that 
it  is  occasionally  replaced  by  fits  of  regular  gout. 

With  regard  to  other  predisposing  causes^  there  is 
little  definitely  known.  The  complaint  exists  among 
all  classes  of  society,  but  on  the  whole  it  is  probably 
most  frequent  among  students  and  brain-workers  in 
general.  A  chronic  condition  of  anaemia  also  seems  to 
be  a  predisposing  cause. 

Much  more  can  be  said  with  regard  to  exciting  causes 
of  the  attacks.  Excitement,  anxiety,  worry,  over-exer- 
tion, whether  mental  or  bodily,  will  often  cause  an 
attack  j  impressions  on  the  nerves  of  special  sense, 
whether  caused  by  disagreeable  odours,  exposure  of  the 


*  "  Gout  and  its  Relations  to  Diseases  of  the  Liver  and  Kidneys,"  5th 
edit,,  p.  93. 


292  CAUSES  OF  MIGRAINE. 

eyes  to  strong  lights  protracted  use  of  the  eyes,  a  visit 
to  a  picture  gallery,  attendance  at  a  concert,  may  have  a 
similar  effect.     Many  patients  know  exactly  the  kind  of 
penalty  they  will  have  to  pay  for  any  mild  kind  of  enjoy- 
ment which  makes. a  decided  impression  on  the  nervous 
system.     Derangement  of  the  stomach   is   not  unfre- 
quently  regarded    as  a   cause  of   migraine,   as  it   is  a 
common  accompaniment  of  the  attacks.     This  view  is 
doubtless  correct  with  regard  to  a  certain  proportion  of 
eases,  but  it  more  often  happens  that  the  gastric  troubles 
result  from  the  nervous  disorder.     In  the  experience  of 
some  patients  the  ingestion  of  food  at  a  time  when  there 
are  slight  warnings  of  an  attack  is  sufficient  to  provoke 
its  onset,  whereas  if  no  food  be  taken  the  symptoms 
will   usually  disappear.     This  experience  is   similar  to 
that  which  warns    most   sufferers  to  keep  as  quiet  as 
possible  and  in  a  darkened  room  when  an  attack  is  sup- 
posed to  be  impending.    The  condition  of  some  patients 
as  regards  sleep  is  closelv  associated  with  the  occurrence 
of  the  attacks.      In  some  persons  subject  to   migraine 
a  sleepless  night  is  almost  invariably  followed  by  the 
well-known  prodromal  symptoms ;  in   others   no  such 
effect  is  observable.     Dr.  Wilks  has  noticed  the  close 
relation    between   headache   and    sleepiness.     Some  of 


PATHOGENY  OF  MIGRAINE,  293 

his  patients  have  stated  that  a  short  nap  after  dinner  is 
followed  by  a  wakeful  and  comfortable  evening,  but  that 
without  such  rest  they  are  drowsy  and  lethargic.  If  in 
this  latter  condition  they  seek  their  bed  they  sleep 
heavily  and  wake  with  a  headache.  Others  have  noticed 
that  "  if  after  a  walk  or  exertion  they  have  felt  tired  and 
sleepy_,  and_,  fearing  the  accustomed  headache,  have  taken 
a  cup  of  coffee  or  tea  to  counteract  the  sleepiness,  they 
have  escaped  the  attack."  Dr.  Wilks  thinks  that  these 
facts  indicate  a  close  connection  between  sleeping  and 
headache;  in  the  latter,  however,  there  are  generally 
indications  of  cerebral  hyperaemia,  whereas  there  is  every 
reason  to  suppose  that  an  opposite  condition  prevails 
during  sleep.  The  influence  of  menstrual  disorders, 
both  .as  predisposing  and  exciting  causes,  has  been 
already  noticed. 

The  pathogeny  of  migraine  is  confessedly  very 
obscure,  but  it  is  obvious  that  the  attacks  are  in  some 
way  connected  with  local  or  general  disorder-  of  the  cir- 
culation. Whatever  the  condition  of  the  affected  parts 
may  be,  it  is,  to  say  the  least,  highly  improbable  that  it 
corresponds  with  that  which  lies  at  the  bottom  of  facial 
neuralgia,  which  differs  fj'om  migraine  in  so  many 
respects.     The  spastic  form   of  the  disorder,  viz.,  that 


294  -P-^  THO  GJENY  OF  MIGRA INE. 

in  which  the  vessels  of  the  affected  half  are  more  or  less 
contracted^  may  be  regarded  as  due  to  irritation  of  the 
cervical  sympathetic,  whilst  the  opposite  condition,  that 
of  vascular  dilatation^  is  caused  by  paralysis  of  the 
same  nerve.  This,  however_,  is  no  real  explanation,  for 
although  the  phenomena  may  be  due  to  anaemia  and 
hyperaemia  respectively,  we  are  still  in  the  dark  as  to 
the  antecedent  cause  of  the  changes  in  the  vaso-motor 
system.  The  seat  of  the  pain  is  also  a  doubtful  point, 
but  it  seems  probable  that  the  dura  mater,  the  pia 
miater,  and  the  sensory  layers  of  the  cortex  are  the 
parts  affected.  The  fifth  nerve  supplies  several  branches 
to  the  dura  mater;  the  pia  mater  is  supplied  from  the 
vertebral  and  carotid  plexus,  and  also  from  several  of 
the  cerebral  nerves,  especially  the  fifth  pair.  According 
to  one  theory,  the  pain  is  due  to  spasm  of  the  muscular 
coat  of  the  vessels ;  it  is  therefore  regarded  as  similar 
in  its  origin  to  the  pain  attendant  upon  spasmodic  con- 
tractions whether  of  the  striped  muscular  fibres,  e.g.,  of 
the  legs,  or  of  the  unstriped  fibres  of  the  bowels  or 
uterus.  This  theory,  however,  does  not  account  for  the 
pain  in  the  opposite  class  of  cases,  or  those  in  which 
the  vessels  are  dilated.  According  to  another  theory, 
the    fluctuations    in    the    supply    of    arterial    blood    as 


PATHOGJENY  OF  MIGRAINE.  295 

observed  in  the  two  opposite  conditions  of  anaemia  and 
hyperaemia  set  up  irritation  of  sensory  nerves  in  any  or 
all  of  the  following  parts — the  skin_,  the  pericranium, 
the  cerebral  membranes,  and  the  sensory  portions  of  the 
cortex.  Such  irritation  is  the  cause  of  the  pain, 
and  that  it  should  be  produced  by  two  such  opposite 
conditions  as  anaemia  and  hyperaemia  is  no  more  ex- 
traordinary than  the  origination  of  epileptiform  con- 
vulsions under  equally  diverse  states  of  the  vascular 
system.  The  other  symptoms  of  migraine_,  e.g.,  the 
cutaneous  hyperaesthesia^  the  disorders  of  the  nerves  of 
special  sense,  the  nausea  and  vomiting,  and  the  copious 
secretions  which  often  accompany  some  portion  of  the 
attack^  may  in  like  manner  be  referred  to  periodical 
fluctuations  in  the  quantity  of  blood  contained  in  the 
peripheral  arteries,  or  in  the  cerebral  centres  of  the 
nerves  supplying  the  affected  parts. 

A  theory  of  migraine,  advanced  by  Dr.  Liveing,  must 
not  be  omitted.  This  author  classes  migraine  with 
several  other  paroxysmal  affections,  e.g.^  epilepsy,  infan- 
tile convulsions,  ague,  and  gout,  and  regards  them  as 
nerve-storms.  He  considers  that  "  the  fundamental 
cause  of  all  neuroses  is  to  be  found  not  in  any  irrita- 
tion of  the  visceral   or  cutaneous  periphery,  nor  in  any 


296  PATHOGENY  OF  MiaRAINE. 

disorder  or  irregularity  of  the  circulation^  but  in  a  pri- 
mary and  often  hereditary  vice  or  morbid  disposition  of 
the  nervous  system  itself;  this  consists  in  a  tendency 
on  the  part  of  the  nervous  centres  to  the  irregular  ac- 
cumulation and  discharge  of  nerve-force.  The  im- 
mediate antecedent  of  an  attack  is  a  condition  of 
unstable  equilibrium  and  gradually  accumulating  tension 
in  the  parts  of  the  nervous  system  more  immediately 
concerned,  while  the  paroxysm  itself  may  be  likened  to 
a  storm  by  which  this  condition  is  dispersed_,  and  the 
equilibrium  for  a  time  restored."  As  supporting  this 
theory.  Dr.  Liveing  insists  upon  the  paroxysmal  and 
explosive  character  of  the  symptoms,  the  intermittent 
nature  of  the  disorder,  the  tendency  to  recurrence  with 
healthy  intervals^  the  nature  and  variety  of  the  exciting 
causes,  and  other  considerations.  The  seat  of  the  dis- 
order is  considered  to  be  "  the  sensory  tract,  and  the 
ganglia  of  the  sensory  nerves,  from  the  optic  thalamus 
above  to  the  nucleus  of  the  vagus  below. ^'  The  storm 
begins  in  the  optic  thalamus,  and  passes  from  above 
downwards,  or  from  before  backwards  in  the  sensory 
tract.* 


*  See  Dr.  Liveing's  work   on  "  Megrim,  Sick   Headache,  and  some 
Allied  Disorders,"  p.  336,  et.  seq. 


DIAGNOSIS  OF  MIGRAINE.  297 

Such  are  the  principal  theories  as  to  the  nature  of 
migraine.  The  view  supported  by  the  late  Dr.  Anstie, 
and  by  some  at  the  present  day,  that  the  disorder  is 
merely  a  variety  of  trigeminal  neuralgia  must,  I  think, 
be  regarded  as  untenable.  • 

The  diagnosis  of  migraine  can  seldom  present  any 
difficulty,  in  spite  of  the  variations  of  the  symptoms  in 
different  cases.  The  pain  differs  from  that  of  true 
neuralgia,  for  it  does  not  come  on  suddenly,  or  take  the 
form  of  darts  or  shocks  separated  by  intervals  of 
freedom.  Moreover,  it  does  not  follow  the  course  of  a 
nerve;  the  supra-orbital  region  and  the  posterior  part 
of  the  roof  of  the  orbit  are  the  commonest  seats  of 
pain.  Tender  points  are  not  discoverable.  The  heat 
and  throbbing  of  the  affected  side  are  also  characteristic 
symptoms,  while  the  vomiting  and  the  evidences  of  con- 
stitutional disorder  are  never  observed  in  connection 
with  tic  douloureux.  The  frequent  termination  of  the 
attack  in  a  heavy  sleep  is  another  distinguishing  feature 
of  migraine.  The  so-called  clavus  hystericus  probably 
resembles  the  pain  experienced  in  many  cases  of 
migraine,  but  the  two  conditions  are  not  likely  to  be 
confounded.  Migraine,  however,  may,  of  course,  occur 
in  hysterical  subjects. 


298  TREATMENT  OF  MIGRAINE. 

The  prognosis  is  favourable  as  regards  any  danger  to 
life^  and  in  some  cases  the  attacks  appear  to  exert  a 
beneficial  effect,  inasmuch  as  the  dread  of  their  occur- 
rence tends  to  restrain  patients  from  various  excesses  to 
which  so  unpleasant  a  penalty  is  attached.  In  a  large 
proportion  of  cases  patients  find  themselves  less  liable 
to  attacks  as  they  advance  in  life,  and  the  symptoms 
become  less  marked.  Much  depends  upon  the  circum- 
stances and  habits  of  life  of  the  patient,  inasmuch  as 
under  favourable  surroundings,  and  with  the  exercise  of 
a  little  common  sense,  measures  can  be  adopted  to 
ward  off  the  attacks,  or  at  least  to  render  them  more 
tolerable. 

Treatment.  Migraine  is  often  a  very  intractable 
affection,  owing  in  a  great  measure  to  the  difficulty  or 
impossibility  of  altering  the  conditions  with  which  it  is 
associated.  Much  may  be  done  for  the  relief  of  patients 
who  are  both  able  and  willing  to  carry  out  a  definite  line 
of  regimen  and  treatment,  but  there  are  not  many 
sufferers  from  migraine  who  can  be  included  in  such  a 
category.  Patients  come  to  look  upon  it  as  a  necessary 
evil,  and  comparatively  few  of  them  seek  and  act  upon 
medical  advice,  except  as  regards  some  medicine  for  the 
relief  of  the  pain.     There  are  a  few  drugs  which,  taken 


TEE  A  TMENT  OF  MIGHAINE.  299 

when  a  paroxysm  is  threatening,  diminish  its  intensity, 
but  their  action  is  variable  and  not  to  be  depended  upon 
in  all  cases.  In  order  to  afford  any  permanent  relief 
the  state  of  the  patient's  general  health  must  receive 
minute  attention,  and  any  existing  cachexia  must  be 
dealt  with  as  far  as  possible.  In  the  majority  of  cases 
tonic  treatment  is  indicated,  and  a  course  of  quinine 
and  iron  sometimes  yields  very  beneficial  results, 
especially  where  there  are  evidences  of  anaemia.  The 
quinine  should  be  given  about  an  hour  before  meals, 
and  the  iron  immediately  after  them.  If  constipation 
be  present,  or  result  from  the  iron,  a  little  extract  of 
aloes  should  be  given  with  the  quinine.  Under  the  use 
of  these  remedies  I  have  known  the  attacks  to  cease  for 
several  months  in  a  young  man  who  had  for  many 
years  been  subject  to  almost  weekly  recurrences. 
Strychnine,  arsenic,  oxide  of  zinc,  and  nitrate  of  silver, 
given  for  a  considerable  time,  have  all  been  found  more 
or  less  efficacious  in  diminishing  the  frequency  of  the 
attacks.  In  women,  any  existing  menstrual  irregulari- 
ties should  receive  careful  attention.  In  cases  of 
migraine  with  a  gouty  family  history,  I  have  witnessed 
much  relief  from  a  combination  of  the  iodides  with 
alkaline  carbonates  and  nux  vomica. 


300  TREATMENT  OF  MIGRAINE. 

As  a  matter  of  course,  in  all  cases  of  migraine  the 
diet  and  general  habits  of  the  patient  are  points  of  much 
importance.  The  food  should  be  nourishing,  easily 
digestible,  moderate  in  quantity,  taken  leisurely  and  at 
regular  intervals.  The  evening  meal  should  always  be  a 
light  one.  Tea  and  coffee  may  be  allowed,  but  always 
in  moderation,  and  with  regard  to  alcoholic  drinks, 
excess  must,  of  course,  be  prohibited,  but  small  quan- 
tities of  those  preferred  by  the  patient  may  be  allowed 
if  taken  with  meals.  Sleep  is  another  important  con- 
sideration, and  patients  should  be  advised  to  make 
every  effort  to  secure  a  proper  amount.  Exercise  must 
not  be  neglected;  its  form  and  duration  'must  be  regu- 
lated by  the  patient's  circumstances,  always  remember- 
ing that  over-exertion  is  likely  to  be  as  mischievous 
as  the  opposite  condition.  The  functions  of  the  skin 
must  likewise  be  attended  to.  A  prolonged  change  of 
air  and  scene  appears  in  some  cases  to  be  remarkably 
beneficial.  A  friend  of  mine  who  had  suffered  severely 
in  England  for  many  years  was  completely  free  from 
attacks  during  a  six  years'  sojourn  in  India.  Some 
patients  have  found  relief  while  staying  at  various 
watering-places,  but  the  effect  seems  to  be  of  a  transi- 
tory character. 


TREATMENT  OF  MIGRAINE.  301 

When  the  sensations  of  the  patient  warn  him  that 
an  attack  is  imminent,  there  are  a  few  measures  which, 
if  adopted,  may  either  prevent  a  paroxysm  or  lessen  its 
severity.  Chief  among  these  is  rest,  either  in  the  sitting 
or  the  horizontal  position,  in  a  darkened  room,  and 
absolute  quiet.  If,  as  often  happens,  the  patient  is 
chilly  and  his  feet  decidedly  cold_,  warmth,  applied 
either  by  means  of  a  hot  bottle  or  bv  sitting  near  a  fire, 
will  be  found,  not  only  grateful,  but  of  much  assistance 
in  warding  off  the  attack.  Some  patients  find  that  a 
small  quantity  of  stimulant  helps  to  shorten  this  stage. 
The  most  useful  drug  is  nux  vomica;  the  best  way 
to  take  it  is  to  mix  10  or  15  minims  of  the  tincture 
with  an  ounce  of  water,  and  to  sip  the  mixture  slowlv. 
In  some  persons  the  effect  of  this  remedy,  especially 
when  combined  with  the  measures  just  adverted  to,  is 
very  satisfactory.  A  full  dose  of  sodium  bicarbonate 
acts  well  in  some  cases,  presumably  in  those  in  which 
the  presence  of  much  free  acid  in  the  stomach  is  the 
exciting  cause  of  the  attack.  If  any  of  these  measures 
afford  even  slight  relief,  the  maintenance  of  the  recum- 
bent position  will  often  induce  sleep,  from  which  the 
patient  awakes  almost  or  altogether  free  from  discom- 
fort. 


302  TREATMENT  OF  MIGRAINE. 

A  remedy  named  antipyrin  has  lately  been  recom- 
mended for  the  relief  of  migraine.  A  single  dose  of 
from  lo  to  15  grains  will  sometimes  cut  short  an  im- 
pending attack.  I  have  witnessed  this  result  in  several 
cases.  Should  the  first  dose  fail  to  relieve,  a  second 
and  even  a  third  dose  may  be  given  at  intervals  of 
twenty  minutes.  Given  in  smaller  doses  for  several 
days  after  an  attack  it  is  said  to  prevent  recurrences. 
It  must  not  be  forgotten  that  even  a  few  grains  of 
antipyrin  sometimes  cause  sickness  and  other  un- 
pleasant symptoms  (see  Lancet ^  Feb.  25,  1888). 

When  the  attack  is  at  its  height^  anything  that  is 
likely  to  relieve  the  pain  is  readily  welcomed  by  the 
patient.  In  not  a  few  cases,  however^  experience  has 
taught  him  that  little  or  nothing  can  be  done  in  this 
direction.  The  horizontal  posture,  a  dark  room,  and 
perfect  quiet  appear  to  be  the  most  effectual  palliatives, 
and  to  these  may  be  added  the  application  of  cold  when 
the  throbbing  and  the  hot  stage  are  present.  An  ice-bag 
placed  on  the  forehead  lessens  the  intensity  of  the  pain. 
If,  as  often  happens,  the  feet  are  cold,  a  hot  water  bottle 
will  also  be  useful.  But  few  patients  would  care  to 
place  their  feet  in  warm  water  owing  to  the  change 
of  position   that  would  be  requisite.      Some   patients 


TREATMENT  OF  MIGRAINE.  303 

find  that  heat  or  a  mustard  plaster  applied  to  the  back 
of  the  neck  affords  relief;  and  compression  of  the 
carotid  on  the  affected  side  is  sometimes  resorted  to 
for  the  same  purpose.  Various  drugs  are  used  with 
more  or  less  advantage  in  different  cases.  When  there 
is  evidence  of  vascular  spasm,  inhalations  of  amyl  nitrite 
are  likely  to  be  serviceable.  From  two  to  four  drops 
may  be  inhaled  from  a  handkerchief,  and  where  the 
remedy  has  a  good  effect  much  relief  is  rapidly  obtained. 
In  the  opposite  condition  of  the  vessels,  ergot  in  some 
form  has  been  found  useful.  It  may  be  administered 
either  in  pills,  in  doses  of  three  or  four  grains,  or  else 
injected  hypodermically  (eight  to  ten  minims  of  the 
Pharmacopoeia  injection).  Cannabis  indica  appears  to 
benefit  some  patients;  from  ten  to  fifteen  minims  of 
the  tincture  maybe  given  every  two  hours  until  relief  is 
obtained.  Bromide  of  potassium  and  chloral  hydrate 
will  assist  other  patients.  The  chloral  is  best  given  in 
a  full  dose  (of  25  or  30  grains),  and  if  it  produce  sleep 
the  patient  will  generally  awake  therefrom  refreshed  and 
free  from  pain.  Butyl-chloral  hydrate  is  recommended 
by  some  authorities,  the  dose  being  five  or  six  grains 
every  three  or  four  hours.  The  hpyodermic  injection  of 
morphine  is  another  remedy  of  this  class,  but  it  is  less 


304  TREATMENT  OF  MIGRAINE. 

efficacious  than  chloral,  and  \s,  moreover,  quite  unsuit- 
able for  cases  in  which  the  attack  has  been  excited  by 
gastric  or  hepatic  derangement. 

There  are  two  drugs,  viz.,  caffeine  and  guarana,  which 
appear  to  have  a  really  marvellous  effect  in  some  cases. 
Unfortunately  their  action  is  very  uncertain  upon  different 
patients  :  some  persons  find  them  utterly  useless.  They 
are,  however,  always  worthy  of  a  trial.  About  20  grains 
of  guarana  should  be  given  when  the  attack  is  coming 
on,  and  followed,  if  necessary,  by  a  second  dose  an  hour 
afterwards.  Under  similar  circumstances  citrate  of 
caffeine  may  be  tried  in  doses  of  from  eight  to  ten  grains. 

As  a  matter  of  course  galvanism  has  been  tried,  both 
as  a  prophylactic  and  as  a  palliative  during  attacks  :  in 
the  latter  capacity  it  sometimes  gives  relief.  A  weak 
current  must  be  used,  one  pole  being  placed  on  each 
mastoid  process.  If  it  be  wished  to  galvanize  the  sym- 
pathetic nerve,  one  pole  is  placed  behind  and  below  the 
angle  of  the  jaw,  while  the  other  pole  is  held  in  the  hand. 
When  the  symptoms  are  referable  to  vascular  dilatation, 
the  negative  pole  should  be  applied  to  the  neck,  while 
the  positive  is  held  in  the  hand  ;  and  when  the  opposite 
condition  exists  the  position  of  the  poles  should  be 
reversed. 


CHAPTER  XII. 

VERTIGO— GIDDINESS. 


Vertigo  as  a  Symptom  of  Organic  Diseases  of  the  Nervous 
System — In  Diseases  of  the  Stomach  and  Liver — In  Affec- 
tions OF  the  Eyes  and  Ears — In  Debility^  and  Anemia,  and 
Functional  Disorders  of  the  Nervous  System — Toxic  Forms 
AS  IN  Gout — Definition  and  Kinds  of  Vertigo — Gastric 
Vertigo,  Symptoms  and  Treatment — Ocular  Vertigo — Aural 
Vertigo  —  Vertigo  of  Anemia,  Neurasthenia,  Hysteria. 
Epilepsy,  and   Hemicrania — Vertigo   in   Gouty  Subjects. 


Vertigo  is  a  common  and  often  a  prominent  symptom 
of  many  organic  diseases  of  the  central  nervous  system, 
e.g.,  of  tumours  of  the  cerebrum,  cerebellum^  crura 
cerebri,  and  pons  Varolii.  It  also  occurs  in  connection 
with  disorders  of  the  stomach  and  liver  -,  as  a  result  of 
certain  affections  of  the  eyes  and  ears ;  in  association 
with  post-nasal  catarrh ;  in  states  of  debility  and 
anaemia ;  and  as  an  effect  of  various  functional  disorders 
of  the  nervous  system.  There  are  also  toxic  forms  of 
vertigo,  examples  of  wdiich  are  seen  in  some  cases  of 
lithsemia,  and  likewise  as  a  result  of  alcohol^  tobacco, 
and  various  other  drugs.      In  a  few  rare  cases  in  which 

20 


3o6  FORMS  OF  VERTIGO. 

giddiness  is  a  prominent  symptom,  no  other  abnormal 
condition  can  be  detected.  At  the  present  time  I  have 
a  patient  under  my  care,  a  gentleman  aged  ^^,  in  whom 
vertigo  is  the  only  symptom,  while  its  cause  remains 
obscure.  The  term  vertigo  implies  a  sense  of  defective 
equilibration,  accompanied  by  a  feeling  of  false  impres- 
sions as  to  the  relations  and  motions  of  surrounding 
objects,  or  of  the  movements  of  the  body,  or  of  the 
brain  itself. 

In  the  most  common  type  of  vertigo,  surrounding 
objects  appear  to  be  in  motion  ;  sometimes  they  seem 
to  be  revolving  round  the  sufferer,  sometimes  to  be 
coming  towards  him,  or  to  be  changing  their  positions 
and  to  stand  at  abnormal  angles  to  each  other.  In 
another  form  the  surrounding  objects  are  at  rest, 
while  the  patient  himself  appears  to  be  in  motion.  In 
a  third  form  the  symptom  is  sometimes  described  as  a 
"  swimming  of  the  head ; "  the  contents  of  the 
cranium  seem  to  be  revolving.  Vertigo,  especially  in 
its  graver  forms,  seldom  exists  alone;  it  is  often 
accompanied  by  a  feeling  of  nausea  or  even  by  vomit- 
ins:,  by  noises  in  the  ears,  confusion  of  thought,  and 
sometimes  even  by  slight  loss  of  consciousness.  The 
various  conditions  with  which  vertigo  is  associated  will 


FORMS  OF  rEUTlGO.  307 

be  first  pointed  out,  and  afterwards  the  pathology  of  the 
symptom  will  be  discussed. 

A  common  form  of  vertigo  is  associated  with  disorder 
of  the  stomach  and  liver.  Men  of  middle  ao'e,  who 
take  an  insufficient  amount  of  exercise  and  eat  hurriedly, 
are  the  most  common  sufferers.  In  some  of  these 
cases,  exercise  after  a  meal  will  bring  on  an  attack. 
There  are  other  persons,  in  whom,  owing  to  a  curious 
idiosyncrasy,  an  attack  of  nausea  and  vertigo  is  the 
invariable  result  of  eating  certain  articles  of  food,  e.g.^ 
shell-fish  and  eggs.  I  have  m.et  with  several  examples 
of  this  character.  When  such  articles  are  taken,  they 
cause  intense  irritation  of  the  stomach,  with  nausea, 
sickness,  and  vertigo,  all  of  which  symptoms  pass  off 
after  the  offending  matters  are  ejected.  In  ordinary 
cases  the  vertigo  comes  on  after  a  hearty  meal.  The 
stomach  becomes  distended,  there  is  pain,  heat,  or 
uneasiness  in  the  head,  buzzing  or  other  noises  in  the 
ears,  eructations,  perhaps  of  an  acid  character,  palpita- 
tion, and  vertigo.  This  last  condition  varies  in  degree, 
and  is  not  unfrequently  so  severe  as  to  create  alarm. 
All  the  surrounding  objects  seem  to  be  in  motion ;  the 
patient,  on  attempting  to  walk,  reels  as  though  he  were 
intoxicated;  sometimes  there  is  double  vision,  flashes  of 


3o8  GASTRIC   VERTIGO. 

light  before  the  eyes^  confusion  of  ideas^  and  great  un- 
easiness. In  some  cases,  but  not  in  all,  the  giddiness 
passes  oflT,  or  is  lessened  when  the  patient  lies  down. 
These  symptoms  may  last  for  several  hours  ;  but  they 
almost  invariably  cease  after  free  vomiting.  The  ejected 
matters  are  often  intensely  acid ;  but  sometimes  bitter 
and  yellowish.  In  less  marked  cases  there  is  only 
nausea  and  retching  as  gastric  symptoms,  and  these, 
with  the  vertigo,  slowly  subside.  The  attacks,  what- 
ever form  they  may  assume,  are  very  apt  to  recur,  and  in 
some  patients  a  condition  of  giddiness  becomes  estab- 
lished, and  lasts  almost  indefinitely,  the  sensation  being 
aggravated  by  movements,  by  mental  efforts,  and  by 
impressions  on  the  nerves  of  special  sense.  In  none  of 
these  cases  is  there  any  loss  of  consciousness,  and  if 
sensory  hallucinations  are  present,  they  are  not  made 
worse  when  the  head  is  lowered,  as  is  the  case  when 
they  are  dependent  on  cerebral  hyperaemia. 

The  treatment  of  gastric  vertigo  consists  first  in 
attention  to  the  diet.  The  food  should  be  of  a  simple 
and  digestible  character,  taken  at  proper  intervals,  and 
without  undue  haste.  Excesses  of  all  kinds  are,  of 
course,  to  be  avoided ;  beer,  pastry,  and  other  substances 
liable  to  engender  flatulence  should   be  forbidden.     In 


OCULAR   VERTIGO.  309 

an  acute  attack,  coming  on  soon  after  a  meal,  if  there 
be  nausea  and  retching,  an  emetic,  such  as  mustard, 
sulphate  of  zinc,  or  ipecacuanha,  should  be  given  and 
followed  by  a  draught  of  lukewarm  water.  If  the 
bowels  are  confined  a  purgative  draught  of  rhubarb, 
magnesia,  and  soda  should  be  "given  a  few  hours  after 
the  emetic  has  acted.  A  course  of  vegetable  bitters 
with  alkalies  will  help  to  ward  off  attacks  for  the 
future.  Trousseau  recommends  a  cup  of  infusion  of 
quassia  every  morning,  and  a  little  soda,  chalk,  and 
magnesia  at  bedtime  and  after  each  of  the  two  principal 
meals.  Nux  vomica  is  also  likely  to  be  serviceable;  ntv-x 
may  be  given  before  meals.  When  the  liver  appears  to 
be  at  fault,  purgatives  are  usually  indicated,  and  the 
Carlsbad  salts  and  the  Rubinat  Condal  water  are  suitable 
for  such  cases.  In  the  more  chronic  forms,  in  addition 
to  purgatives,  a  course  of  dilute  nitro-muriatic  acid 
with  nux  vomica  and  henbane  will  probably  afford  relief. 
Attention  to  the  diet  is  all-important. 

Vertigo  from  ocular  causes  generally  depends  upon 
paralysis  of  the  external  rectus  muscle  of  one  eye. 
Diplopia  is  caused  thereby,  and  is  associated  with  con- 
fusion of  vision,  and  these  symptoms  with  the  giddiness 
may  become  so   severe  that  the  patient  fears  to  walk 


3IO  OCULAR   VERTIGO. 

alone   in  the  streets.     Loss  of  power  of  the  internal 
recti  muscles  is  another  cause  of  vertigo^  and  this  con- 
dition is  not  unfrequent  in  persons  whose  daily  occupa- 
tion involves  the  continuous  use  of  the  eyes  at  reading 
distance.     In  maintaining  the  necessary  convergence  of 
the  visual  lines  the  internal  recti  become  strained  and 
gradually  insufficient;  prolonged  use  of  the  eyes  causes 
aching  pain  and  confusion  of  vision,  with  headache  and 
a  feeling   of  giddiness.     All  these  symptoms  become 
aggravated  if  the  patient's  health  fail  from  any  cause/or 
if  any  special  strain   be   put   upon  the  eyes.     On   the 
other  handj  after  regt_,  change  of  air_,  and  a  general  tonic 
treatment    the    vertigo    and   the    other  symptoms    are 
always  less  troublesome.     Astigmatism  and  asthenopia 
from  defective  accommodation  are  less  frequent  causes 
of    vertigo.     In    connection    with    ocular   defects  it  is 
worthy  of  notice  that  even  when  slight  they  may  induce 
and  greatly  exaggerate  giddiness^  due  primarily  to  gastric 
or  aural  causes.     In  persons  liable  to  these  latter  forms 
of  vertigo  the  use  even  of  normal  eyes  is  liable  to  cause 
or  increase  the  giddiness. 

The  treatment  of  vertigo  due  to  ocular  causes  con- 
sists in  remedying  the  defect  in  the  eyes,  either  by  suit- 
able glasses  or  by  operation. 


AURAL    VERTIGO.  311 

Aural  vertigo_,  to  which  much  attention  has  been  paid 
since  its  pathology  was  explained  by  Meniere  in  1860^ 
is  to  be  regarded  as  the  effect  of  irritation  of  the  nerves 
of  the  semicircular  canals.  The  vertigo  is  associated 
with  auditory  sensations  of  a  severe  character.  The 
acute  attacks  are  generally  preceded  by  pain  in  one  ear, 
deafness_,  and  more  or  less  discharge,  and  occasionally 
by  sensations  of  chilliness ;  but  in  some  cases  they  come 
on  suddenly  and  without  any  warning.  The  patient 
feels  giddy  and  sick^  and  is  conscious  of  a  loud_,  buzzing, 
whistling,  or  cracking  noise  in  one  ear;  the  face  becomes 
covered  with  a  cold  perspiration,  and  in  rare  cases  sensa- 
tion and  power  of  motion  are  almost  completely  abolished. 
In  an  ordinary  attack  consciousness  is  not  impaired  and 
movement  is  possible,  though  not  in  a  straight  line. 
This  condition  was  very  marked  in  a  case  I  saw 
recently  in  consultation  with  Dr.  Woakes.  Neighbour- 
ing objects  appear  to  oscillate  or  to  revolve  round  the 
patient;  he  reels  or  totters  as  though  the  ground  were 
moving  under  his  feet;  and  sometimes  he  is  conscious 
of  an  irresistible  tendency  to  keep  turning  in  the  same 
direction.  The  impulse  is  from  right  to  left  when  the 
right  ear  is  affected,  and  vice  versa.  These  symptoms 
may  last  for  a  few  seconds  only,  or  may  continue  for 


312 


AURAL   VERTIGO. 


several  hours,  and   they  sometimes  pass  off  after  free 
vomiting.     The  patient   may    then  feel   quite  well,  or 
may    still    complain    of    uneasiness    about    the    head, 
especially    on    movement.       Diminution     or    loss    of 
hearing    is    commonly    noticed    after    the    first   attack, 
when  the  latter  has  occurred  without  any  premonitory 
symptoms.     In  some  patients  the  giddiness  and  noises 
in   the  ears  are  almost    habitual^    becoming    worse   at 
intervals.     In    ordinary    cases   the    giddiness  and    im- 
pairment of  hearing  are  the  only    remaining   troubles, 
and  the  former  may  soon  pass  off;    but  in  more  severe 
and  complicated  cases  there  are  clonic  spasms  of  the 
muscles  of   the    face,    involuntary    movements  of   the 
limbs,   causing  the  patient   to   run  forwards  or  fall  in 
various  directions.       I   have  a   patient    suffering   from 
aural  disease,  in  whom  the  noises  continue  for  months 
and    then    stop    suddenly,    and    cease    altogether    for 
several  weeks,   again  to  recur.     Once  established,  the 
attacks  of  aural   vertigo  are  apt  to  recur  at  uncertain 
intervals,  and   their  incidence   has   no   relation   to    the 
state  of  the  digestion.     If  the   deafness  becomes  com- 
plete,   cessation    of   the    attacks    is    the   general     rule. 
Aural  vertigo  is  liable  to  be  mistaken  for  giddiness,  the 
result  of  cerebral  congestion.     In  this  latter  condition 


AURAL   VERTIGO.  313 

there  are  frequently  intervals  of  decided  loss  of  con- 
sciousnesSj  from  which  recovery  is  gradual  and  tedious, 
so  that  mental  confusion  and  embarrassment  may  last 
for  some  time.  Deafness  is,  however,  absent,  and  the 
prodromal  symptoms  are  more  often  visual  than 
auditory  illusions.  Loss  of  consciousness  is  charac- 
teristic  of  epileptic  vertigo;  on  recovery  the  epileptic 
patient  has  no  knowledge  of  what  has  gone  before^  and 
there  is  no  impairment  of  hearing. 

Recent  experiments  have  served  to  explain  the 
pathology  of  auditory  vertigo.  Section  or  injury  of 
the  semicircular  canals  of  the  labyrinth  produces  a 
feeling  of  giddiness  and  consequent  disturbances  of 
equilibrium.  A  normal  condition  of  the  labyrinth  is 
necessary  for  the  maintenance  of  the  balancing  power. 
According  to  Dr.  Ferrier^  this  portion  of  the  ear  seems 
to  regulate  the  state  of  the  equilibrium  of  the  individual 
and  to  preside  over  co-ordination.  Dr.  Crum  Brown 
suggests  that  the  sense  of  rotation  has  a  special  peri- 
pheral organ_,  a  bram-centre,  and  a  connecting  sensory 
nerve.  All  experimenters  agree  that  the  labyrinth  is  a 
special  organ  of  this  character;  the  irritation  is 
•conveyed  by  the  auditory  nerve  to  the  centre,  with 
the  result  of  producing  anaemia  of  certain  parts  of  the 


.SI 4  •  AVUAL    I'ERTIGO. 

brain.  The  vertigo_,  reelings  and  other  symptoms  are 
held  to  depend  upon  the  last-mentioned  condition. 
Irritation  of  the  external  and  middle  ear  will  sometimes 
produce  vertigo.  Thus  the  injection  of  cold  water  into 
the  meatus  and  the  presence  of  foreign  bodies  are 
occasional  causes  of  the  condition,  while  in  the  middle 
ear  inflammatory  processes  and  obstruction  of  the 
Eustachian  tube  may  lead   to  a  similar  result. 

In  the  treatment  of  aural  vertigo^  the  ear  should  be 
examined  in  the  hope  that  a  removable  cause  may  be 
discovered.  Hardened  wax  and  foreign  bodies  should, 
of  course^  be  removed,  and  obstruction  in  the  Eustachian 
tube  must  be  dealt  with  by  inflating  the  tympanum,  as- 
tringent applications  to  the  pharynx,  and,  if  necessary,  by 
passing  the  Eustachian  catheter.  Labyrinthine  vertigo, 
is  much  less  amenable  to  treatment.  The  most  useful 
remedy  during  the  intervals  is  quinine  in  large  doses, 
e.g.,  gr.  x-xv  daily,  combined  with  dilute  hydrobromic 
acid,  and  continued  for  three  or  four  weeks.  The 
bromides,  in  full  doses,  are  sometimes  useful  in  severe 
attacks,  and  the  addition  of  morphine  may  also  be  tried. 
For  chronic  cases,  counter-irritation  over  the  mastoid 
process  is  likely  to  prove  serviceable.  Attention  should 
be  paid  to  any  gastric  derangement,  for  in  the  subjects. 


AURAL    I'ERTIGO.  315 

of  aural  vertigo,  disorder  of  the  stomach  is  liable  to 
provoke  an  attack.  It  must  not  be  forgotten  that  when 
the  deafness  becomes  complete  and  permanent^  the  ver- 
tiginous attacks  generally  cease. 

Dr.  Woakes*  has  pointed  out  that  the  condition  of 
the  Eustachian  tubes  in  post-nasal  catarrh^  of  which 
indigestion  is  a  frequent  concomitant^  exerts  a  marked 
influence  on  the  induction  of  the  so-called  stomach 
vertigo.     The  result  of  the  obstruction   of  the  tubes  is 

retraction  of  the  drum- membrane,  "in  consequence  of 

• 
the  external  atmospheric  pressure  not  bemg  counter- 
balanced by  the  column  of  air  behind  it,  which  should 
be  constantly  renewed  by  the  automatic  action  of  the 
Eustachian  tubes  upon  the  respired  air.  This  function 
being  in  abeyance  the  air  is  excluded  from  the  tympanic 
cavitv  and  hence  the  greater  or  less  degree  of  collapse 
of  the  drum-heads.  With  this  the  ossicles  are  also 
pressed  inwards,  and  through  the  medium  of  the  stapes 
exert  a  slightly  increased  degree  of  tension  upon  the 
intra-Iabyrinthine  fluid,  which  constitutes  a  predispos- 
ing  cause    of  vertigo.      Now  the   subjects    of  chronic 


*  "  On  Post-Nasal  Catarrh  and  Diseases  of  the  Nose  causing  Deaf- 
ness," p.  52. 


3i6  VERTIGO  AND  BEBILITY. 

catarrh  are  particularly  prone  to  attacks  of  vertigo,  which 
attacks  are  frequently  initiated  in  the  primce  viceJ' 

In  various  conditions  of  debility,  as  anaemia  and 
neurasthenia,  more  or  less  severe  vertigo  is  a  some- 
what common  symptom.  It  always  attends  copious 
losses  of  blood,  and  is  felt  by  the  patient  before  actual 
syncope  comes  on.  In  ordinary  anaemia  and  in  chlorosis, 
patients  often  complain  of  giddiness  especially  on  exertion. 
There  is  seldom  any  difficulty  in  recognizing  these  condi- 
tions, and  the  main  question  in  diagnosis  relates  to  the 
cause.  This,  of  course,  must  be  discovered  and  dealt 
with,  and  the  giddiness  and  the  other  cerebral  symptoms 
will  then  subside.  In  neurasthenic  subjects,  vertigo  is 
seldom  very  severe,  though  it  may  continue  for  some 
time  and  cause  great  distress  to  the  patient.  It  is 
always  aggravated  by  the  gastric  and  hepatic  disorders 
and  the  sleeplessness,  all  of  which  are  common  com- 
plaints in  these  subjects.  As  a  symptom,  vertigo  is  apt 
to  be  most  prominent  in  those  cases  of  neurasthenia 
which  are  mainly  due  to  sexual  excesses.  It  is  worse 
when  the  patient  assumes  the  erect  position,  and  while 
he  is  walking  there  is  a  distressing  sense  of  unsteadi- 
ness. There  is  no  deafness,  and  noises  in  the  ears  are 
rarely    complained    of;    the    vertigo    is   aggravated    by 


VERTIGO  AND  NERVOUS  DISORDERS.  317 

mental  efforts  of  various  kinds,  and  by  prolonged  use 
of  the  eyes.  The  treatment  is,  of  course,  that  of  the 
condition  of  which  the  vertigo  is  only  a  symptom. 
Avoidance  of  the  cause  is  indispensable  to  a  cure. 

Among  functional  nervous  disorders,  besides  those 
already  mentioned,  hysteria,  epilepsy,  and  hemicrania 
count  vertigo  among  their  symptoms.  Dr.  Weir 
Mitchell  states  that  he  has  "^seen  hysterical  girls  with 
deafness,  tinnitus  and  a  great  development  of  equili- 
bria! disturbance,  in  whom  the  disease  passed  away 
without  leaving  a  trace  behind  it.^'  He  adds  that 
vertigo  in  such  cases  does  not  exclude  the  presence  of 
true  aural,  optic,  or  gastric  dizziness,  which  is  then  apt 
to  become  the  starting-point  of  a  long  train  of  hysterical 
disorders.  In  epileptic  cases  the  attack  may  be  ushered 
in  or  replaced  by  a  feeling  of  giddiness.  Epileptic  vertigo 
is  always  accompanied  by  unconsciousness,  and  often 
by  various  motor  phenomena  and  some  of  the  other 
ordinary  symptoms  of  the  typical  epileptic  paroxysm. 
The  vertiginous  fee]ine;s  in  an  attack  of  migrraine  are 
seldom  severe,  unless  the  patient  happen  to  be  travellina: 
during  the  attack.  The  giddiness  may  precede  or 
accompany  the  pain  in  the  head,  and  it  is  often  marked 
when  the  gastric  symptoms  are  prominent,  and  subsides 


3i8  VERTIGO  AND   GOUT. 


after  free  vomiting.  There  is  neither  deafness  nor  noise 
in  the  ear;  bat  various  ocular  symptoms  of  migraine 
are  generally  associated  with  the  giddiness.  The  treat- 
ment of  these  forms  of  vertigo  is,  of  course,  that  of  the 
conditions  with  which  they  are  associated. 

Vertigo  is  somewhat  frequent  in  gouty  subjects,  and 
in  some  of  these  cases  it  forms  one  of  a  group  of 
symptoms  which  alternate  with  or  occasionally  replace 
the  articular  inflammation.  Under  such  circumstances 
it  is  apt  to  be  accompanied  by  headache,  disturbed  sjeep, 
flatulence,  and  other  signs  of  gastric  disorder.  It  is 
probably  due  to  the  presence  of  lithic  acid  and  other 
imperfectly  oxidized  substances  in  the  blood,  and  not 
unfrequently  to  the  presence  of  undigested  and  irritating 
articles  of  food  in  the  stomach  and  bowels.  The  treat- 
ment is  that  of  gouty  dyspepsia ;  the  diet  must  be 
carefully  regulated;  excess  of  animal  food  and  indiges- 
tible articles  must  be  strictly  forbidden;  stimulants,  if 
allowed  at  all,  should  be  prescribed  in  definite  and  small 
quantities,  to  be  taken  only  with  meals ;  exercise  and 
attention  to  the  state  of  the  skin  should  be  carefully 
insisted  on.  By  way  of  medicines,  purgatives  are 
generally  indicated,  and  these  may  be  taken  in  the  form 
of  such    mineral   waters    as    Friedrichshall,    ^sculap, 


VERTIGO  AND  GOUT.      .  319 


Hunyadi  Janos^  or  the  Rubinat-Condal.  When  there 
are  marked  symptoms  of  gastric  catarrh^  such  as  fer- 
mentation and  acid  eructations^  Carlsbad  water  is 
preferable.  Should  the  function  of  the  liver  appear  to 
be  imperfectly  performed^  small  doses  of  calomel  or 
blue  pill,  either  alone  or  in  combination  with  colocynth 
or  rhubarb^  m.ay  be  given  from  time  to  time.  Various 
other  hepatic  stimulants  and  alteratives,,  as  podophyllin^ 
euonymin,  iridin,  and  leptandrin,  are  available  for  use  in 
chronic  cases.  When  the  urine  'contains  much  free 
acid,  a  course  of  alkalies  with  bitter  tonics  is  likely  to 
be  serviceable.  Vertigo  in  cases  of  gastric  disorder  is 
explained  by  the  close  .relation  which  exists  between  the 
nuclei  of  origin  of  the  pneumogastric  and  auditory 
nerves  ;  the  irritation  is  propagated  from  the  former  to 
the.  latter.  In  lithaemia  the  giddiness  is  presumably 
due  to  the  irritating  effect  of  the  lithic  acid  upon  the 
cerebral  vessels,  and  the  consequent  disturbance  of  the 
circulation. 


CHAPTER   XIII. 

WRITER'S    CRAMP   AND    ALLIED    DISORDERS. 


Writer's  Cramp,  Peculiarities  of — Persons  Most  Prone  to 
Suffer  —  Pathology — Symptoms,  Three  Forms:  Spastic, 
Tremulous,  and  Paralytic — Mixed  Forms — Allied  Disorders 
Diagnosis — Treatment -^  Rest  —  Wolff's  Method  —  Gal- 
vanism— Attention  to  General  Health — Local  Measures — 
Counter-irritation — Mechanical  Appliances. 


The  condition  termed  writer's  cramp  is  the  most 
common  example  of  a  class  of  peculiar  disorders  of 
motion.  These  affections  present  one  feature  which  is 
common  to  them  all,  namely,  that  certain  actions,  pre- 
viously accomplished  with  perfect  ease,  are  rendered  diffi- 
cult or  even  impossible  in  consequence  of  cramp  or  other 
disordered  form  of  muscular  action,  whereas  other  kinds 
of  movement  are  performed  by  the  same  muscles  with- 
out difficulty  or  discomfort.  As  a  matter  oF  course,  the 
upper  extremity,  and  particularly  the  hands  and  fingers, 
are  most  liable  to  be  thus  affected,  inasmuch  as  these 
parts  have  more  work  thrown  on  them.  The  cases  in 
which  the  lower  extremities  are  affected  are  compara- 
tively few  in  number. 


WRITER'S  CRAMP.  321 

Writer's  e ramp  occurs  almost  exclusively  in  persons 
whose  avocations  require  them  to  write  for  many  hours 
daily.  The  majority  of  the  sufferers  are  those  who  are 
compelled  to  write  a  good  legible  hand  and  overtax  their 
muscles.  It  is  said  that  bad  writers  and  authors  for 
the  most  part  escape ;  copyists  have  to  bear  the  burden. 
Weakly  subjects  with  a  predisposition  to  nervous  affec- 
tions are  most  liable  to  be  attacked^  and  when  the 
symptoms  have  appeared  they  are  apt  to  be  aggravated 
by  excesses  of  all  kinds,  and  in  fact  by  anything  which 
tends  to  lower  the  tone  of  the  nervous  system. 

In  a  few  cases  the  symptoms  have  been  noticed  to 
appear  after  an  injury  to  the  hand;  their  development 
is^  doubtless,  often  promoted  by  the  use  of  hard  steel 
pens,  a  thin  and  rigid  penholder,  and  by  the  adoption 
of  a  cramped  and  confined  position  when  writing.  The 
fear  and  anxiety  lest  the  disorder  should  prevent  the 
sufferer  from  gaining  a  living  will  also  tend  to  accelerate 
the  progress  of  the  symptoms. 

Nothing  definite  can  be  stated  with  regard  to  the 
pathology  of  this  affection.  The  symptoms  indicate 
disordered  co-ordination,  and,  as  Dr.  Poore  has  pointed 
out,  such  disorder  would  be  produced  by  "  the  failure  of 
one  muscle,  however  small,  which  had  been  taught  by 

11 


322  SYMPTOMS  OF  WRITER'S  CRAMP. 

years  of  laborious  education  to  act  in  harmony  with 
many  others  for  the  accomphshing  of  a  compHcated 
and  dehcate  act."  It  has  been  thought  by  some  that 
degenerative  changes  take  place  in  the  spinal  cord_,  and 
this  opinion  is  supported  by  the  fact  that  faradisation  of 
the  hands  has  no  effect  upon  the  symptoms.  More- 
over, if  the  left  hand  is  used  to  supply  the  place  of  the 
right  it  is  soon  apt  to  become  affected  in  asimilar  manner. 
It  may  be  that  slight  inflammatory  changes  are  set  up 
in  the  peripheral  nerves,  and  that  the  process  gradually 
advances  towards  the  nerve-centres. 

Symptoms.  These  are  of  a  typical  character,  inas- 
much as  they  occur  only  when  an  attempt  is  made  to 
use  the  pen.  They  begin  gradually  and  insidiously ; 
there  is  at  first  a  sense  of  discomfort  in  the  hand  and 
arm  generally,  and  the  guidance  of  the  pen  seems  to  be 
difficult.  As  time  goes  on  the  symptoms  become  more 
marked,  and  after  a  few  letters  or  words  are  written  the 
hand  becomes  stiff,  or  painful,  or  both  at  the  same 
time.  In  the  most  common  form  of  the  affection  the 
thumb  and  index  finger  are  thrown  into  a  state  of  tonic 
spasm  soon  after  the  patient  attempts  to  write,  and  it  is 
obvious  that  certain  muscles,  or  groups  of  muscles,  are 
spasmodically  contracted.     In  some  cases  the  thumb  is 


SYMPTOMS  OF  WRITER'S  CRAMP.  323 

drawn  across  the  palm,  and  thus  pressed  against  the 
pen;  in  others  the  index  finger  is  firmly  extended; 
while  in  a  third  class  extension  of  the  thumb  is  added 
to  that  of  the  forefinger,  so  that  it  is  impossible  to  hold 
the  pen  in  the  ordinary  manner.  In  very  severe  cases 
the  hand  is  drawn  to  the  ulnar  side  owing  to  spasm  of 
the  flexor  and  extensor  carpi  ulnaris.  It  less  frequently 
happens  that  the  pronators  and  supinators  are  affected; 
in  very  rare  cases  the  muscles  of  the  shoulder  are  spas- 
modically contracted.  When  the  hand  is  affected,  as 
above  described,  writing  becomes  very  difficulty  and  the 
letters  are  apt  to  be  unequal  and  distorted,  and  separated 
from  each  other  by  irregular  strokes. 

In  a  second  form  of  the  disorder,  immediately  the 
patient  attempts  to  write,  the  hand,  and  perhaps  the 
entire  arm,  begin  to  tremble,  the  movements  become 
worse  as  the  patient  endeavours  to  overcome  them,  and 
•legible  writing  is,  of  course,  impossible.  In  the  third, 
or  paralytic  form,  the  hand  and  arm  feel  weak  and  pain- 
ful after  a  few  words  or  lines  have  been  written;  if 
writing  be  persevered  in,  the  hand  at  last  is  felt  to  have 
lost  its  strength,  and  it  rests  for  some  time  on  the 
paper  in  order  to  recover  itself.  As  a  general  rule  other 
movements  can  be  performed  without  difficulty  by  the 


324  SYMPTOMS  OF  WRITER'S  CRAMP. 

affected  hand,  and  no  discomfort  is  felt  exctj  t  when 
writing;  but  as  time  goes  on  the  muscles  at  the  back  of 
the  forearm  are  liable  to  continue  painful,  especially 
when  called  into  action  for  any  purpose.  The  pain 
may  also  extend  to  the  nerves  on  the  inner  side  of  the 
arm  and  to  the  shoulder. 

These  three  forms  of  writer^s  cramp  may  be  combined 
in  various  ways;  tremulous  movements  are  often  super- 
added to  the  spasm.  Various  manoeuvres  are  adopted 
by  patients  in  order  to  overcome  their  difficulties ;  they 
often  try  holding  the  pen  in  a  different  way,  and  for  a 
time  they  may  find  relief,  but  at  last  the  different 
muscles  called  into  play  become  similarly  affected. 
Writing  from  the  wrist  alone,  or  even  from  the 
shoulder,  is  often,  for  a  time  at  least,  efficacious,  and 
patients  always  find  that  they  can  write  more  comfort- 
ably with  a  pencil  than  with  a  pen.  A  feeling  of  tired- 
ness is  common  to  all  the  patients,  but  it  is  especially 
marked  in  those  who  suffer  from  the  spastic  form  of  the 
disorder.  They  are  apt  to  make  enormous  efforts  in 
order  to  overcome  their  difficulties.  The  pain  already 
described  may  extend  from  the  shoulder  to  the  spine, 
and  the  lower  cervical  and  upper  dorsal  vertebrae  are 
not  unfrequently  tender  on  pressure.     An  eruption  of 


DIAGNOSIS  OF  WRITER'S  CRAMP.  325 

eczema,  with  severe  tingling  at  the  back  of  the  forearm, 
has  been  noticed  in  some  cases.  The  electrical  excita- 
bility of  the  affected  muscles  is  generally  normal,  but  it 
may  be  somewhat  increased. 

When  the  pain  and  stiffness  have  become  marked, 
the  handwriting  is,  of  course,  considerably  altered ;  the 
letters  are  stiff,  angular,  and  ill-formed.  The  complaint 
is  a  very  obstinate  one;  a  complete  cure  can  be  expected 
only  in  slight  cases.  The  chronic  and  severe  forms 
may,  however,  be  considerably  relieved  by  treatment. 
Some  patients  learn  to  use  the  left  hand,  but  this,  as 
before  stated,  is  apt  to  become  similarly  affected.  I 
have  a  patient  who  has  learnt  to  write  with  his  left 
hand,  and  by  using  the  hands  alternately  has  prevented 
a  recurrence  of  the  attack. 

With  reference  to  disorders  allied  to  writer's  cramp  it 
is  only  necessary  to  mention  their  names.  The  most 
common  instances  are  as  follows  :  Piano-  and  violin- 
players'  cramp,  telegraphists'  cramp,  and  tailors'  cramp. 
In  the  lower  extremities  analogous  symptoms  are  occa- 
sionally witnessed  in  ballet-dancers  and  in  girls  working 
treadle  sewinsf-machines. 

The  diagnosis  of  writer's  cramp  is  almost  always 
easily  made.     It  is  only  necessary   to   remember  that 


326  TEJEATMJENT  OF  WRITER'S  CRAMP. 

difficulties  in  writing  are  sometimes  the  first  symptom 
of  chorea. 

Treatment.  Rest  of  the  affected  part  is  all-important^ 
and  for  mild  cases  may  be  all  that  is  necessary.  It 
must,  however_,  be  continued  for  weeks  or  even  months, 
and  when  the  patient  recommences  writing  he  should 
do  very  little  at  a  time/  adopt  a  comfortable  position, 
wear  a  glove  on  his  hand,  use  a  large  soft  cork  pen- 
holder and  an  easy  pen.  In  severe  cases  something 
more  than  rest  is  required,  and  systematic  massage 
would  appear  to  have  yielded  very  favourable  results  in 
the  hands  of  specialists. 

The  method  employed,  with  a  considerable  amount 
of  success,  by  J.  Wolif,  is  as  follows: — (i)  Twice  or 
three  times  daily,  the  patient  is  directed  to  move  his 
fingers,  hands,  forearms,  and  arms  in  all  possible  direc- 
tions, the  muscles  '^  being  made  to  contract  from  six 
to  twelve  times  with  considerable  force  and  with  a 
pause  after  each  movement,  the  whole  exercise  not 
exceeding  thirty  minutes."  (2)  The  movements  are 
made  as  before,  but  '^each  one  is  arrested  by  another 
person  in  a  steady  and  regular  manner;  this  may  be 
repeated  as  often  as  the  active  exercise.  Massage  is 
practised  daily  for  about  twenty  minutes,  beginning  at 


TBIIATMIINT  OF  WRITER'S  CRAMP.  327 

the  periphery  ;  percussion  of  the  muscles  is  considered 
an  essential  part  of  the  massage.  Combined  with 
these  are  peculiar  lessons  in  pen-prehension  and 
writing."*  Dr.  Lewis  cites  the  experience  of  Theodor 
Stein^  according  to  whom,  out  of  277  cases  thus  treated, 
157  were  cured,  22  improved,  .while  q8  remained  un- 
improved. The  total  number  comprised  cases  of 
writers',  pianists',  telegraphers',  and  knitters'  cramp. 

In  a  considerable  number  of  patients,  much  improve- 
ment has  also  been  effected  by  the  use  of  galvanism, 
the  application  of  which,  however,  must  be  adapted  to 
each  particular  case.  As  a  general  rule  weak  currents 
alone  are  necessary,  and  violent  contractions  of  the 
muscles  and  long  sittings  are  to  be  avoided.  In  one 
method  the  anode  is  applied  to  the  spinous  processes 
of  the  lower  cervical  and  upper  dorsal  vertebrae,  while 
the  cathode  is  placed  over  the  affected  muscles  or  their 
nerves.  The  poles  are  not  to  be  moved  about,  but 
should  be  kept  in  position  for  about  ten  minutes,  and 
the  treatment  may  be  repeated  either  daily  or  every 
other  day.  In  another  method,  the  anode  is  placed  as 
before,  over  the  lower  cervical  or  upper  dorsal  vertebrae. 


*  "  Neural    Disorders  of   Writers  and  Artisans,"  by  Dr.  M.  J.  Lewis, 
in  Vol.  V.  of  "  Pepper's  System  of  Practical  Medicine.'' 


328  TRI:ATMENT  of  WRITER'S  CRAMP. 

and  the  cathode  in  the  depression  between  the  angle  of 
the  lower  jaw  and  the  sterno-cleido-mastoid  muscle. 
A  mild  current  should  be  used,  it  should  not  be 
suddenly  broken,  and  the  sitting  should  not  exceed 
five  minutes.  When,  as  not  unfrequently  happens,  one 
or  more  spinous  processes  are  tender  to  the  touch,  the 
application  of  the  anode  will  generally  relieve  this 
symptom  and  produce  a  corresponding  improvement  in 
the  state  of  the  arm.  The  faradic  current  is  not  to  be 
recommended  in  these  cases  of  writer's  cramp  except, 
perhaps,  in  the  paretic  forms,  and  after  the  spastic  sym- 
ptoms have  entirely  disappeared.  In  these  cases  the 
nutrition  of  the  muscles  may  be  promoted  by  the 
cautious  use  of  the  induced  current.  One  electrode 
should  be  placed  over  the  affected  muscles,  and  the  other 
on  the  patient^s  chest ;  a  weak  current  just  enough  to 
cause  contraction  of  the  muscles  is  all  that  is  required, 
and  the  application  should  not  be  continued  for  more 
than  five  minutes. 

In  all  cases  of  writer's  cramp  the  state  of  the  general 
health  should  be  inquired  into  and  improved  as  far  as  pos- 
sible. Anaemia  should  be  combated  by  iron,  quinine,  and 
the  hypophosphites ;  if  nervous  irritability,  anxiety,  and 
sleeplessness  are  prominent  symptoms,  a  short  course 


tei:atmjent  of  writer's  cramp.         329 

•of  the  bromides,  in  combination  with  the  tonic  remedies, 
is  likely  to  be  serviceable.  Pain  in  the  arm  should  be 
relieved  by  belladonna  and  chloroform  liniment.  Some 
authorities  recommend  the  hypodermic  injection  of 
atropine  (gr.  -^)  for  cases  in  which  tonic  contraction  is 
a  marked  feature.  When  pain  extends  up  the  inner 
side  of  the  arm  it  is  probably  due  to  neuritis,  and  should 
be  treated  by  the  application  of  flying  blisters  to  the 
neighbourhood  of  the  painful  spots.  In  very  severe 
cases  it  may  be  better  to  apply  the  Paquelin  cautery  to 
the  skin.  The  instrument  must  be  at  a  white  heat,  and 
very  quickly  and  firmly  drawn  along  the  course  of  the 
affected  nerves.  If  properly  applied,  vesication  will  not 
be  produced ;  only  the  superficial  layer  of  skin  becomes 
dry  and  brown.  The  length  of  the  cauterized  surface  need 
not  exceed  a  couple  of  inches,  and  the  application  should 
be  repeated  from  time  to  time  on  fresh  portions  of  skin. 
Various  mechanical  appliances  have  been  devised  for 
enabling  the  subjects  of  writer's  cramp  to  continue 
their  avocation  to  some  extent.  Such  appliances  act 
by  making  another  set  of  muscles  perform  the  work. 
They  are  of  questionable  efficacy  inasmuch  as  the  sym- 
ptoms are  apt  to  become  developed  in  the  muscles 
whose  vicarious  action  is  solicited. 


CHAPTER    XIV. 

FACIAL    PARALYSIS. 


Forms  of  Functional  Paralysis — Rheumatic  Paralysis — Paraly- 
sis OF  THE  Facial  Nerve,  due  to  Cold  and  other  Influ- 
ences— Symptoms,  Subjective  and  Objective — Loss  of  the 
Sense  of  Taste — Auditory  Symptoms — Electrical  Reactions 
of  the  Paralyzed  Parts — Diagnosis  of  Facial  Paralysis — 
Determination  of  the  Site  of  the  Lesion — Prognosis — 
Treatment. 


The    term   functional    is    applied    to    those   forms    of 
paralysisj    the    cause    of    which    is    either    obscure    or 
altogether  unknown.     Thus    under  this   heading  may 
be  grouped  the  paralyses  met  with  in  chronic  poisoning 
by   lead    and    mercury ;    those  which   are   observed   as 
sequelae  of  febrile  affections,  such  as  diphtheria,  dysen- 
tery,  and    intermittent   fever;    the   paralyses    of  reflex 
origin,  and  those  which  occur  in  hysterical  cases.    With 
the  exception  of  the  last,  all  these  forms  are  compara- 
tively rare,  but  another  form  more  often  met  with,  and 
vaguely  termed  rheumatic^  may  be  included  in  the  cate- 
gory of  functional  paralyses,  inasmuch  as  the  anatomical 
condition  of  the  affected  nerve  is  unknown.     The  most 
common  example  of  rheumatic  paralysis  is  that  which 


CAUSES  OF  FACIAL  PARALYSIS.  331 

involves  the  facial  nerve,  which,  from  its  superficial  and 
exposed  position,  is  especially  liable  to  be  influenced  by 
changes  of  temperature.  The  paralysis  referred  to  is 
almost  always  unilateral ;  facial  diplegia  is  a  symptom 
of  bulbar  paralysis,  and  is  rarely,  if  ever,  seen  as  a  con- 
sequence of  cold. 

In  the  majority  of  cases  exposure  to  cold,  especially 
in  the  form  of  a  cold  wind,  is  the  exciting;  cause  of 
facial  paralysis.  Persons  in  good  health  are  liable  to  be 
thus  attacked  after  sitting  at  an  open  window,  for 
example,  of  a  railway  carriage.  A  decided  current  of 
air  is  not  absolutely  necessary,  inasmuch  as  remaining 
in  a  damp  place,  as  in  a  new  house  with  imperfectly 
dried  w^alls,  has  been  known  to  produce  it.  It  is  also 
stated  that  violent  emotions,  as  terror,  grief,  or  anger, 
have  been  the  only  assignable  causes  in  some  cases. 
Nothing  is  definitely  known  as  to  the  nature  of  the 
anatomical  change  which  takes  place.  It  may  be  sup- 
posed that  there  is  slight  inflammatory  swelling,  followed 
by  exudation  in  the  sheath  of  the  nerve.  When  this 
process  takes  place  within  the  aqueduct  of  Fallopius  the 
results  will  be  more  marked  than  when  the  peripheral 
part  of  the  nerve  is  affected.  According  to  another 
theory  the  cold  affects  the  sensory  nerves  of  the  skin. 


332  CAUSES  OF  FACIAL  PARALYSIS. 

and  the  paralysis  is  due  to  reflex  inhibitory  influence. 
When  the  loss  of  power  follows  violent  emotional 
excitement^  the  nuclei  at  the  origin  of  the  facial  nerve 
must  be  paralyzed  by  an  influence  transmitted  to  them 
from  the  higher  cerebral  centres. 

It  is  necessary  to  say  a  few  words  on  the  other 
causes  of  facial  paralysis.  The  severest  forms  are  ob- 
served in  cases  of  caries  of  the  temporal  bone  in  which 
the  nerve  maybe  completely  destroyed.  Simple  catarrh 
of  the  tympanum  may,  however,  cause  facial  paralysis. 
Owing  to  the  near  proximity  of  the  two  structures, 
inflammation  may  easily  extend  from  the  one  to  the 
other.  Wounds  are  a  not  unfrequent  cause  of  facial 
paralysis,  and  inflammatory  swellings  in  the  neighbour- 
hood of  the  parotid  gland,  and  glandular  and  other 
tumours  near  the  stylomastoid  foramen  may  produce 
the  same  result.  Another  category  includes  those 
causes  which  are  intracranial,  and  of  these  the  most 
common  are  tumours  and  periosteal  growths,  especially 
those  of -a  syphilitic  nature  at  the  base  of  the  skull. 
Intracerebral  lesions,  affecting  the  facial  nuclei  in  the 
medulla  oblongata,  or  the  motor  centres  in  the  cerebral 
cortex,  are  other  causes  of  facial  paralysis. 

Patients  are  generally  made  aware  of  the  occurrence 


SYMPTOMS  OF  FACIAL  PARALYSIS.  S33 

of  facial  paralysis  by  finding  that  fluids  taken  into  the 
mouth  have  a  tendency  to  escape  on  one  side,  and  that 
solid  morsels,  after  mastication,  remain  between  the 
gums  and  the  cheek.  Pain  on  the  affected  side,  due  to 
implication  of  the  fifth  nerve,  is  rarely  experienced,  but 
there  is  often  a  feeling  of  stiffness.  When  the  paralysis 
has  come  on  slowly,  e.g.,  several  days  after  exposure  to 
cold,  the  patients  are  sometimes  conscious  of  some  loss 
of  taste,  as  well  as  of  deafness  and  noises  in  the  ear  of 
the  affected  side  as  premonitory  symptoms. 

When  the  paralysis  is  complete,  that  is,  when  all  the 
branches  of  the  nerves  are  involved,  the  objective 
symptoms  are  very  distinct.  The  surface  of  the  face  is 
drawn  towards  the  sound  side ;  on  the  paralyzed  side 
the  folds  and  wrinkles  are  obliterated  and  the  face 
therefore  presents  a  smooth  appearance,  the  angle  of  the 
mouth  is  lower  than  normal,  the  nostril  does  not  rise  in 
inspiration,  but  sinks  owing  to  the  pressure  of  the 
atmosphere.  The  objective  symptoms  become  much 
more  marked  when  the  patient  attempts  to  use  the 
muscles  of  the  face,  as  in  laughing,  crying,  making 
grimaces,  etc.  On  the  paralyzed  side  no  wrinkles  are 
then  seen  on  the  forehead ;  the  closure  of  the  eye  is 
incomplete ;  the  eyeball  is  rolled  upwards,  so  that  only 


334  SYMPTOMS  OF  FACIAL  PAMALYSIS.      . 

the  sclerotic  is  seen;  the  angle  of  the  mouth  cannot  be 
drawn  toward  the  ear;  the  lips  cannot  be  moved  in  any 
direction^  and  when  the  patient  endeavours  to  whistle 
the  difference  becomes  very  obvious.  When  he  laughs 
or  cries  the  mouth  is  opened  only  on  the  sound  side. 
Moreover,  the  eyelids  do  not  blink,  the  eye  remains 
open  and  conjunctivitis  is  apt  to  be  set  up^  the  tears  do 
not  find  their  way  into  the  lachrymal  canal,  but  course 
downwards  over  the  cheek.  The  patient  finds  it  difficult 
to  pronounce  the  labial  consonants,  and  in  speaking  the 
affected  side  of  the  face  remains  flat.  The  paralysis  is 
sometimes  found  to  affect  one  side  of  the  soft  palate  and 
uvula. 

Partial  loss  of  taste  is  frequently  met  with  in  these 
cases  of  facial  paralysis.  The  lingual  nerve  is  the  nerve 
of  taste  for  the  anterior  part  of  the  tongue,,  and  it  owes 
this  endowment  to  the  chorda  tympani  nerve.  This 
nerve  leaves  the  facial  within  the  aqueduct  of  Fallopius, 
passes  across  the  membrana  tympani  to  emerge  at  the 
Glaserian  fissure_,  and  finally  unites  with  the  lingual 
nerve.  If  the  facial  be  affected  before  giving  off  this 
branch,  the  fibres  of  the  chorda  tympani  will  become 
involved  and,  as  a  result,  there  will  be  loss  or  diminu- 
tion of  the  sense  of  taste  on  the  anterior  two-thirds  of 


SYMPTOMS  OF  FACIAL  PARALYSIS.  335 

the  tongue.  This  loss,  if  not  noticed  by  the  patient, 
may  be  detected  by  placing  a  few  grains  of  salt,  or  a 
drop  or  two  of  vinegar,  or  of  some  bitter  tincture  on 
the  surface  of  the  tongue.  Dryness  of  the  mouth  on 
the  affected  side  is  observed  in  some  cases,  and  this  is 
due  to  implication  of  those  fibres  of  the  chorda  tympani 
which  supply  the  parotid  gland.  x\uditory  troubles  are 
more  common;  they  may  be  due  to  disease  of  the 
tympanum,  and  in  that  case  would  take  the  form  of 
deafness  ;  or  they  may  appear  as  excessive  acuteness 
of  hearing,  a  condition  presumably  due  to  paralysis  of 
the  stapedius  muscle  which  is  supplied  by  a  branch  of 
the  facial.  When  the  action  of  this  muscle  is  in  abey- 
ance, the  stapes  becomes  somewhat  loose,  so  that  all 
impulses  from  the  tympanum  act  upon  it  more  vigor- 
ously, and,  as  a  result,  more  considerable  vibrations  take 
place  in  the  fluid  of  the  internal  ear. 

In  these  cases  of  facial  paralysis  there  is  no  loss  of 
sensation  on  the  affected  side.  When  the  complaint  is 
of  peripheral  origin  reflex  movements  are  not  excited  on 
touching  the  conjunctiv^a  or  on  irritating  the  skin  of 
the  face.  Signs  of  trophic  disorder  are  rare,  but  they 
are  sometimes  noticed  in  severe  and  chronic  cases,  when 
they  take  the  form   of  atrophy  of  the  affected  cheek. 


336  SYMPTOMS  OF  FACIAL  PARALYSIS. 

The  electrical  condition  of  the  muscles  is  of  great 
importance  with  regard  to  diagnosis  and  prognosis. 
The  electrical  excitability  is  diminished  in  cases  in 
which  the  facial  paralysis  is  a  symptom  of  lesion  of  the 
medulla  oblongata  ;  but  it  is  not  affected  in  the  paralysis 
which  is  associated  with  ordinary  hemiplegia.  Cases 
of  rheumatic  facial  paralysis  may  be  divided  into  three 
classes  according  to  the  electrical  reactions  which  are 
presented. 

1.  In  the  slight  forms  the  electrical  irritability  is 
normal^  or  only  very  little  increased;  the  prognosis  is 
favourable_,  the  paralysis  usually  subsiding  within  a  week 
or  ten  days. 

2.  In  more  severe  cases  the  muscles  at  first  show 
increased  irritability  to  both  faradism  and  galvanism; 
gradually^  however_,  the  effect  of  the  former  becomes 
less  and  less^  while  that  of  galvanism  is  preserved  and 
may  be  even  still  more  exaggerated.  The  irritability  of 
the  nerve  to  both  forms  is  diminished^  but  not  entirely 
lost.  Severe  degenerative  changes  have  not  as  yet  set 
in;  the  prognosis  is  not  unfavourable;  the  paralysis 
may  subside  in  four  or  five  weeks. 

3.  In  very  severe  forms  the  reaction  of  degeneration 
is  pronounced.     The  symptoms  then  are:  diminution 


BIA GNOSIS  OF  FA CIAL  PA BALYSIS.  337 

or  complete  loss  of  the  faradlc  and  galvanic  excitability  of 
the  nerve  ;  loss  of  the  faradic  excitability  of  the  muscles  : 
quantitative  increase  and  qualitative  changes  of  the  gal- 
vanic and  increase  of  the  mechanical  irritability  of  the 
muscles.  The  prognosis  is  unfavourable ;  but  after  several 
months  the  paralysis  may  subside,  leaving  behind  it  some 
amount  of  stiffness  and  contraction  of  the  muscles. 

The  diagnosis  of  facial  paralysis  is  for  the  most  part 
easily  made.     In  severe  cases  the  condition  is  detected 
at   once;  the   want  of  symmetry  in  the  face  is  quite 
evident.     In  slight  cases  the  change  is  rendered  per- 
ceptible when  the  patient  attempts  to  use  the  muscles 
of  expression^  and   when  he  purses  up  his  lips  as  if  to 
whistle.     It  is  a  point  of  great  importance  to  determine 
whether  the  symptoms  are  due  to  a  peripheral  or  to  a 
central  cause ;  in  the  former  case  all  the  branches  of  the 
nerve   are  equally  involved.     The  paralysis  affects  the 
branches  distributed  to  the  forehead  and  eyelids,  whereas 
these  parts  remain  free  in  cerebral  cases.     The  reaction 
of  degeneration  and  the  absence  of  reflexes  are  additional 
indications  of  a  peripheral  origin.    In  cerebral  cases  the 
electrical    excitability    and    the    reflexes    are    preserved, 
while   other    symptoms   due   to   the   paralysis   of  other 
cerebral  nerves  are  always  present. 

22 


338  PR6gN0SI8  OF  FACIAL  PARALYSIS. 

A  consideration  of  the  course  and  anatomy  of  the 
facial  nerve  enables  us  to  discover  the  site  of  the  lesion 
in  peripheral  cases.  Thus^  when  the  nerve  is  affected 
outside  the  aqueduct  of  Fallopius,  paralysis  of  the 
muscles  of  the  face  is  the  only  result ;  the  muscles  of 
the  external  ear  will  be  paralyzed  when  the  lesion  extends 
into  the  aqueduct^  but  not  as  far  as  the  origin  of  the 
chorda  tympani.  When  the  lesion  is  between  the 
chorda  tympani  and  the  nerve  which  supplies  the 
stapedius  muscle,  in  addition  to  paralysis  of  the  facial 
muscles,  there  will  be  some  loss  of  taste  and  perhaps 
diminution  of  the  salivary  secretion.  If  the  lesion  is 
between  the  nerve  to  the  stapedius  and  the  geniculate 
ganglion  there  will  be  abnormal  acuteness  of  hearing,  to 
which  will  be  added  paralysis  of  the  velum  palati  if  the 
neighbourhood  of  the  ganglion  be  involved.  Lastly,  if 
the  lesion  be  situated  above  the  geniculate  ganglion 
there  will  be  the  disorders  just  mentioned^  but  no  dimi- 
nution of  taste.  The  hearing  may  be  interfered  with, 
as  the  lesion  will  probably  affect  the  auditory  nerve. 

In  most  cases  of  rheumatic  facial  paralysis  the 
prognosis  is  good,  but  the  symptoms  may  last  for 
a  considerable  time :  I  have  seen  several  cases  of 
this  kind.     Troublesome    sequelae   are    sometimes   ob- 


TREA  T 211: NT  OF  FA  CIA  L  PARAL  YSIS.  339 


served  ;  some  of  the  facial  muscles  become  con- 
tracted and  rigid  ;  the  zygomatici  are  especially  liable 
to  be  thus  affected,  and  this  rigidity  is  sometimes 
associated  with  spasmodic  contractions  of  the  orbicu- 
laris palpebrarum,  and  of  various  muscles  about  the 
mouth.  In  non-rheumatic  cases  the  prognosis  depends 
on  the  nature  of  the  lesion ;  in  cerebral  hemiplegia  the 
facial  symptoms  are  usually  the  first  to  disappear,  but  in 
syphilitic  cases  they  are  apt  to  be  very  obstinate. 
The  muscles  of  the  forehead  and  about  the  eye  usually 
recover  before  those  of  the  mouth.  Some  amount 
of  disfigurement^  observable  when  the  patient  laughs, 
sometimes  persists  after  the  disappearance  of  other 
'symptoms. 

For  the  proper  treatment  of  facial  paralysis  every 
attempt  should  be  made  to  discover  the  cause.  If  due 
to  cold,  hot  fomentations  should  be  assiduously  applied 
to  the  side  of  the  head  and  face;  purgatives  are 
generally  useful,  and  some  iodide  of  potassium  with 
alkalies  may  be  given  for  a  few  days.  The  patient,  of 
course,  must  be  kept  warm  and  quiet.  In  cases  in 
which  there  is  a  history  of  syphilis  the  iodides  in  full 
doses  are  especially  indicated,  and  mercury  should  be 
given  if  these  fail  to  cause  improvement.     By  way  of 


340  TREATMENT  OF  FACIAL  PARALYSIS. 

expediting  the  cure  the  muscles  should  be  carefully 
faradized ;  it  sometimes  happens  that  an  improvement 
is  manifested  after  one  such  application.  In  severe 
cases,  and  whenever  the  nmscles  will  not  respond  to 
faradism_,  the  galvanic  current  should  be  used ;  the 
positive  pole  being  placed  in  the  auricular  fossa^  while 
the  negative  pole  is  applied  over  the  individual  muscles. 
The  strength  of  the  current  must  be  carefully  graduated, 
and  should  never  be  more  than  sufficient  to  produce 
distinct  contraction.  It  is  sometimes  advantageous  to 
make  alternate  applications  of  galvanism  and  faradism. 
In  severe  cases  the  treatment  may  have  to  be  continued 
for  several  months,  and  when  no  improvement  becomes 
visible  it  is  best  to  discontinue  the  applications  for  three 
or  four  weeks,  and  then  to  renew  them.  During  this 
interval  the  patient  should  be  instructed  to  rub  and 
knead  the  muscles.  When  contraction  has  taken 
place  electricity  should  not  be  applied  to  those  muscles, 
but  rubbing  and  kneading  alone  should  be  practised. 
For  obstinate  cases  of  paralysis^  in  which  electricity  has 
been  applied  without  avail,  the  subcutaneous  injection  of 
strychnine  may  be  carefully  tried.  From  gr.  3-V-2V  ^^ 
the  nitrate  of  strychnine  may  be  thus  employed. 


CHAPTER   XV. 

HYPOCHONDRIASIS. 


Hypochondriasjs,  Definition  and  Forms — Causes — Hereditary 
Predisposition  —  Habits  of  Life  —  Gout — Abdominal  anu 
Sexual  Disorders — Subsidiary  Causes — Symptoms — Influence 
OF  Attention — Mental  Disorder — Illusions — Disorders  of 
Sensation — Disorders  of  Motion — Impotence — Vaso-^Iotor 
Disturbances — Course  and  Prognosis — Diagnosis — Treat- 
ment— Existing  Ailments  to  be  Attended  to — Gouty  Cases 
— Rest  and  Recreation — Change  of  Air  and  Scene,  and 
Suitable  Occupation. 


Hypochondriasis  necessarily  occupies  an  indefinite 
place  in  the  category  of  nervous  disorders.  In  some 
cases  the  symptoms  are  so  distinct^  severe,  and  perma- 
nent as  to  place  the  existence  of  mental  unsoundness 
beyond  all  doubt;  in  others  the  patients  could  not  with 
fairness  be  described  as  insane.  Tn  other  words,  the 
hypochondriacal  state  is  sometimes  on  the  one,  some- 
times on  the  other  side  of  the  line  which  separates  the 
neuroses  from  the  mental  disorders  properly  so-called. 
It  may  be  defined  as  a  form  of  mental  depression  in 
which  the  attention  of  the  patient  is  principallv  or  con- 
stantly directed  to  the  state  of  his  body  or  mind.     The 


342  CAUSES  OF  STPOCSONDSIASIS. 

organ  or  part  which  is  the  seat  of  painful  sensations 
may  be  really  diseased^  and  under  such  circumstances  the 
condition  is  sometimes  termed  ^'  hypochondria  cum 
materia/^  while  the  v^^ords  ''  hypochondria  sine 
materia  "  are  used  to  describe  cases  in  which  no 
disease  can  be  recognized. 

Hypochondriasis  is  most  common  in  men  of  middle 
age;  hereditary  predisposition  to  nervous  disorder  is 
often  traceable ;  and  effeminate  habits  and  easy  circum- 
stances favour  the  development  of  the  complaint.  An 
out-door  life  tends  to  ward  off  hypochondriasis;  studi- 
ous, sedentary  habits_,  combined  as  they  often  are  with 
insufficient  exercise,  have  a  directly  opposite  effect.  An 
outbreak  of  the  symptoms  may  be  produced  by  mental 
agitation  or  mental  fatigue,  by  witnessing  disease  in 
others,  and  by  indulging  in  a  habit  only  too  common 
in  these  days,  viz.,  that  of  reading  medical  works 
adapted  to  the  popular  understanding.  Among  patho- 
logical conditions  often  associated  with  hypochondriasis^ 
functional  disorder  of  the  abdominal  organs  occupies 
the  first  place.  Congestion  of  the  liver  and  haemorr- 
hoids are  sometimes  associated  with  hypochondriasis  ; 
I  have  recently  seen  a  marked  case  of  this  character  in 
consultation  with  Mr.  Alfred  Cooper.     The  patient  had 


SYMPTOMS  OF  HYPOCHONDRIASIS.  343 

suffered  from  piles  for  years^  and  was  the  victim  of 
profound  hypochondriasis.  His  mental  condition 
rapidly  improved  after  Mr.  Cooper  had  successfully 
operated  upon  the  haemorrhoids.  A  gouty  habit  of  body 
predisposes  to  hypochondriasis^  which^  in  some  cases,  is 
cut  short  when  an  acute  attack  of  gout  supervenes. 
Next  in  frequency  come  various  affections  of  the  sexual 
organs^  often  more  imaginary  than  real_,  always  exagger- 
ated by  the  amount  of  attention  devoted  to  them,  and 
in  not  a  few^  cases  by  the  study  of  obscene  literature. 
Not  a  few  male  hypochondriacs  believe  themselves  to 
be  suffering  from  spermatorrhoea.  As  subsidiary  causes 
of  hypochondriasis  must  be  mentioned  severe  diseases 
and  their  sequelae,  the  immoderate  use  of  tea,  coffee, 
and  tobacco_,  especially  the  last-named.  Hypochon- 
driasis may  be  associated  with  any  organic  lesion,  and 
the  latter  may  be  discoverable  only  on  post-mortem 
examination.  Nothing  is  known  of  the  seat  and 
nature  of  the  mental  disorder. 

In  the  majority  of  cases  of  hypochondriasis,  the 
symptoms  become  gradually  developed.  Given  a  ten- 
dency to  mental  depression,  the  slightest  disorder  of 
any  part  of  the  body,  or  the  most  trifling  indication 
thereof,  is  regarded  as  a  matter  of  the  highest  import- 


344  SYMPTOMS  OF  HFPOCHONDRIASIS. 

ance,  and  the  gloomiest  apprehensions  are  excited.  The 
attention  becomes  closely  fixed  upon  the  sensations 
which  emanate  from  the  affected  part,  with  the  result 
of  aggravating  any  existing  lesion,  and  even  of  induc- 
ing real  disorder  in  organs  previously  sound.  The 
influence  of  attention  upon  the  action  of  the  heart  is 
often  manifested  in  these  cases;  when  the  conscious- 
ness is  directed  to  it,  its  contractions  are  quickened  or 
otherwise  disturbed.  When  pain  is  complained  of  and 
the  attention  is  centred  on  the  part,  the  conductivity  of 
the  nerve  fibres  is  augmented,  so  that  very  slight  irrita- 
tion gives  rise  to  marked  sensations.  A  vicious  circle 
becomes  thus  established  ;  weak  peripheral  irritation 
produces  a  severe  effect  on  nerv^e-centres  which  are 
abnormally  sensitive;  the  impressions  are  thence  trans- 
mitted to  other  peripheral  nerves  with  increase  of  the 
excitement  and  irritability,  and  corresponding  aggrava- 
tion of  the  mental  state  of  the  patient. 

The  symptoms  of  the  mental  disorder  are  lowness  of 
spirits,  uneasiness,  profound  anxiety,  and  marked  irrita- 
bility. In  severe  cases  the  patient's  own  feelings 
occupy  his  attention  to  the  exclusion  of  everything 
else;  he  becomes  egotistical  to  the  [last  degree.  The 
intelligence  may   seem  to   be   impaired,  for  the   hypo- 


SYMPTOMS  OF  MTPOCEONDRIASIS.  345 

chondriac  engrossed  in  his  own  thoughts  is  incapable 
of  that  degree  of  mental  effort  which  would  enable  him 
to  understand  the  thoughts  and  feelings  of  others.  This 
condition  is  often  permanent,  and  no  further  change 
takes  place^  but  if  the  patient  is  not  satisfied  with  the 
natural  explanation  of  his  troubles  and  attributes  them 
to  impossible  or  supernatural  influences,  the  condition 
is  one  of  true  monomania. 

In  some  cases  the  illusions  are  connected  with  per- 
ception. The  patient  hears  imaginary  noises,  or  has 
visions_,  and  sees  persons  or  things  which  are  non- 
existent. For  some  time  he  may  recognize  the  true 
nature  of  his  perceptions^  and  may  laugh  at  them  as 
absurd  j  if,  on  the  other  hand,  he  believes  them  to  be 
real,  and  acts  on  such  belief,  he  is  obviously  of  unsound 
mind.  In  rare  cases  the  patient  fears  to  touch  certain 
objects  or  persons  under  the  idea  that  some  maleficent 
influence  proceeds  from  them.  Some  hypochondriacs 
are  very  inquisitive,  and  are  constantly  investigating  the 
causes  of  things.  They  do  not  propose  real  problems, 
but  ask  useless  questions,  e.g.,  why  any  given  article 
has  such  and  such  a  name,  or  why  its  shape  is  not 
other  than  it  is,  etc. 

Disorders  of  sensation  are  always  present  in  hypo- 


346  SY3IPT0MS  OF  SYPOCSONBJRIASIS. 

chondriacal  subjects^  and  constitute  indeed  the  ground- 
work of  their  complaints.  Any  internal  organ  may  be 
the  seat  of  peculiar  sensations,,  increasing  in  severity 
until  they  amount  to  severe  pain.  The  most  common 
seats  of  suffering  are  the  chest  and  abdomen,  especially 
under  the  false  ribs,  the  locality  from  u'hich  the  name 
of  the  affection  is  derived.  Uneasiness  or  pain  in  the 
epigastrium,  pains  in  the  head,  especially  about  the 
occiput,  and  perverted  sensations  in  various  parts  of  the 
body  are  always  present  in  different  degrees.  Anaes- 
thesia is  less  common,  and  when  present  is  usually 
confined  to  limited  areas.  Disorders  of  motion  are  far 
less  common,  but  in  ■  some  cases  there  are  obvious 
fibrillary  twitchings  of  various  muscles,  and  these  may 
extend  and  cause  cramp.  In  rare  cases  the  pharyngeal 
muscles  and  some  of  the  muscles  of  respiration  are 
prone  to  spasmodic  contraction,  probably  under  the 
influence  of  some  dominant  idea. 

Some  hypochondriacs  suffer  from  the  group  of  sym- 
ptoms termed  "  agoraphobia,-'-'  but  these,  of  course,  are 
in  no  way  peculiar  to  them.  In  the  commonest  form  of 
this  condition  the  patient  finds  it  impossible  to  cross  an 
open  space,  for  when  he  attempts  to  do  so  he  is  stopped 
by    a    sensation    of  sinking    and   weakness,    which    is 


PEOGNOSIS  OF  SYPOCHONDBIASIS.  347 

accompanied  by  a  feeling  of  pressure  in  the  cliest, 
palpitation  of  the  hearty  and  pallor  of  the  countenance. 
The  feeling  of  powerlessness  subsides  if  the  slightest 
help  is  rendered^  or  even  if  the  patient  imagines  that 
assistance  is  forthcoming.  The  symptoms  are_,  how- 
ever, liable  to  be  very  troublesome,  and  are  often 
permanent    in    these    cases. 

Male  hypochondriacs  are  often  impotent,  the  loss  of 
pauper  depending  on  mental  causes,  and  increased  by 
ineffectual  attempts  at  coition.  Any  form  of  true 
paralysis  of  the  voluntary  muscles  is  very  rare;  but,  on 
the  other  hand,  defective  action  of  the  muscular  coat  of 
the  intestines,  as  shown  by  constipation,  is  one  of  the 
commonest  symptoms.  The  feet  and  hands  are  often 
cold,  and  the  secretions  of  the  liver,  stomach,  and 
bowels  are  always  more  or  less  disordered,  as  results,  it 
may  be  presumed,  of  vaso-motor  disturbance. 

When  a  condition  of  hypochondriasis  suddenly 
supervenes,  it  is  generally  traceable  to  some  specific 
cause,  and  most  of  these  cases  admit  of  a  favourable 
prognosis.  As  a  general  rule,  however,  the  complaint 
is  gradually  and  slowly  developed,  and  pursues  a 
chronic  course,  seldom  exhibiting  any  permanent 
improvement.      The   symptoms    may,    however,    remit 


348  BIA  GNOSIS  OF  JEYP  0  C SON  DEI  A  SIS. 

from  time  to  time,  the  patient  during  these  intervals 
appearing  almost  or  quite  free  from  his  troubles.  A 
fatal  termination  is  of  rare  occurrence  as  an  immediate 
consequence  of  hypochondriasis,  but  the  power  of 
resisting  injurious  influences  is  much  diminished,  and 
the  patient  is  especially  liable  to  be  attacked  by  various 
diseases,  and  notably  by  those  of  an  infectious  character. 
Suicide  is  seldom  attempted  by  hypochondriacs  unless  a 
condition  of  melancholia  has  supervened.  The  prognosis 
is  unfavourable  in  cases  w^ith  hereditary  predisposition 
to  nervous  disorders^  and  when  the  symptoms  appear 
in  early  life.  Hypochondriacal  insanity  is  quite 
incurable.  Hypochondriacal  symptoms,  even  of  a  grave 
character,  have  been  observed  to  cease  on  the  superven- 
tion of  an  acute  attack  of  illness. 

The  diagnosis  of  hypochondriasis  is  for  the  most  part 
easily  made.  The  patient  should  be  very  carefully 
^examined  in  order  to  ascertain  whether  there  are  any 
material  grounds  for  his  beliefs  and  statements.  Hypo- 
chondriasis in  some  respects  resembles  melancholia,  but 
there  are  marked  differences  between  typical  examples 
of  the  two  conditions.  The  hypochondriac  is  always 
dwelling  upon  his  symptoms,  and  constantly  talks 
about  his  health.     He  is  quite  willing  to  use  remedies. 


TRUA  TMUNT  OF  SYP 0  CRONDEIA SIS.  349 

and  goes  from  one  medical  adviser  to  another,  and 
listens  with  eagerness  to  any  new  suggestion.  He  has 
no  wish  to  cut  short  his  troubles  by  suicide,  even  when 
he  imagines  they  must  have  a  fatal  termination.  In 
melancholia  the  patient  is  often  taciturn,  and  seldom 
communicative  on  the  subject  of  his  troubles.  He  is 
always  despondent,  and  rarely"  discusses  any  methods 
which  might  relieve  his  symptoms,  for  he  considers 
them  to  be  incurable.  Melancholic  patients  often 
evince  a  strong  tendency  to  suicide. 

The  satisfactory  treatment  of  a  case  of  hypochon- 
driasis requires  a  considerable  amount  of  tact  and 
patience  on  the  part  of  the  physician.  He  must  spare 
no  endeavour  to  gain  the  patient's  confidence;  he  must 
not  deny  the  subjective  reality  of  the  suffering  while  he 
explains  the  want  or  insufficiency  of  any  objective 
basis.  The  patient  must,  of  course,  be  carefully 
examined,  and  it  is  well  to  let  the  first  examination  be 
thorough  and  complete,  so  as  to  be  able  to  say  that 
nothing  has  been  overlooked.  Any  obvious  source  of 
trouble  must  be  carefully  dealt  with;  any  symptoms  of 
indigestion  will  require  appropriate  treatment.  Consti- 
pation often  exists  in  these  cases,  and  invariably  aggra- 
vates the  general  condition.     It  should   be  dealt  with 


3'50  TREATMENT  OF  HFPOCHONBEIASIS. 

by  attention  to  diet  and  exercise^  and  if  purgatives  are 
required  aloes  will  generally  be  found  the  most  suit- 
able. A  combination  of  extract  of  aloes^  quinine^  and 
extract  of  belladonna  is  well  adapted  for  these  cases; 
moderate  and  regular  action  of  the  bowels  is  all  that  is 
necessary.  In  cases  with  a  history  of  gout,  a  course  of 
alkalies  with  bitter  tonics,  combined  with  purgatives^  is 
likely  to  be  serviceable.  Exercise,  a  moderate  diet,  and 
attention  to  the  state  of  the  skin  are  especially  neces- 
sary for  these  cases.  A  course  of  iron  will  be  useful 
where  there  are  evidences  of  anaemia. 

When  all  possible  causes  of  the  disorder  have  been 
attended  to,  treatment  of  a  more  general  character 
should  be  adopted,  and  it  should  be  prescribed  immedi- 
ately in  those  cases  in  which  there  are  no  objective 
indications.  When  the  condition  is  due  to  overwork, 
or  appears  to  be  associated  with  the  opposite  condition, 
viz.,  lack  of  suitable  employment,  the  treatment  is 
obvious.  Patients  belonging  to  the  former  class  require 
rest  and  recreation,  while  the  lazy  and  indolent  should 
be  encouraged  to  follow  a  better  way  of  life.  In  either 
case  change  of  scene,  as  obtained  in  foreign  travel,  and 
exercise  are  the  means  most  likely  to  be  successful. 
The  recreation  must  be  adapted  to  the  individual;  if  the 


TEH  A  TMENT  OF  HYP  O  CHONDEIA  SIS.  3  5 1 

muscular  strength  be  good  and  the  thoracic  organs 
sound,  a  sojourn  for  some  time  in  a  mountainous  dis- 
trict, where  the  hmbs  can  be  exercised  in  pure  air,  and 
where  all  the  surroundings  are  conducive  to  health  and 
vigour,  will  yield  good  results  in  many  cases  of  hypo- 
chondriasis. Dyspeptic  symptoms  will  speedily  vanish, 
and  the  mind  will  throw  off  the  cloud  which  had 
oppressed  it.  Any  outdoor  recreation  which  interests 
the  patient  will  help  him  to  get  rid  of  his  nervous 
troubles.  The  same  advice  should  be  given  to  the  idle 
and  indolent  hypochondriac  ;  employment  of  some 
kind  should  be  found  for  him,  and  if  he  can  be  induced 
to  take  an  active  interest  in  some  work  of  charity  he 
may  be  regarded  as  having  taken  a  very  important  step 
towards  recovery.  As  soon  as  he  begins  to  feel  for 
others  and  to  interest  himself  in  them  his  own  troubles 
will  begin  to  disappear.  In  advanced  cases  of  hypo- 
chondriasis, with  more  or  less  decided  delusions,  it  is 
advisable  to  place  the  patient  in  a  well-managed  institu- 
tion. 


SECTION   II. 

FUNCTIONAL  DISORDERS  OF  THE  ORGANS 
OF  CIRCULATION. 


INTRODUCTORY   CHAPTER. 


Peculiar  Features  of  Functional  Disorders  of  the  Heart — 
Difference  Between  Functional  and  Organic  Affections — 
Symptoms  of  Functional  Disorders,  Either  the  Movements 
or  the  Sensations  of  the  Organ  Affected — Disturbances  of 
Rhythm — Causes  of  Functional  Disorder  of  the  Heart — 
Predisposing  Causes  —  Dr.  Shapter's  Classification  —  Sym- 
ptoms often  Accompanying  Palpitation — Diminished  Impulse 
Associated  with  Depression  and  Anxiety' — Necessity  of 
Examination  into  Habits  and  Circumstances — Inorganic 
Murmurs — Cases  of  Cardiac  Exhaustion — Dr.  Hartshorne's 
Experience — The  Irritable  Heart — Study  of  the  Cardiac 
Nervous  Apparatus  —  The  Intra-Cardiac  Ganglia  —  The 
Pneumogastric  Nerves — Cardiac  Sensory  Fibres — The  Sym- 
pathetic Nerve — The  Depressor  Fibres  of  the  Vagus — 
Summary  of  the  Circumstances  Affecting  the  Frequency  of 
the  Heart's  Action. 


Functional  disorders  of  the  heart  are  of  frequent 
occurrence,  and,  owing  to  the  importance  of  the  organ, 
they  are  often  the  source  of  much  inconvenience,  dis- 
tresSj  and  even  danger.  The  symptoms  to  which  they 
give  rise  are  identical  with  some  of  those  which  are  the 

^3 


354  FUNCTIONAL  CARDIAC  DISORDERS. 

result  of  organic  affectioiis_,  and  they  are  apt  to  cause 
much  anxiety  and  apprehension  on  the  part  of  the 
patient^  lest  he  may  be  suffering  from  incurable  disease. 
There  is  another  peculiarity  about  the  symptoms,  viz., 
that  those  of  functional  disorder  may  supervene  from 
time  to  time  in  cases  in  which  organic  disease  exists, 
without  any  necessary  mutual  dependence.  A  correct 
diagnosis  is,  therefore,  of  great  importance,  both  for  the 
satisfaction  of  the  patient  and  for  determining  the  treat- 
ment to  be  pursued.  The  duty  of  the  physician  is  to 
ascertain  the  circumstances  that  are  incompatible  with 
the  idea  of  mere  functional  disorder,  and,  secondly, 
those  which  are  quite  compatible  with  it.  The 
following  are  the  principal  features  of  a  general 
character,  which  serve  to  distinguish  the  two  classes  of 
disorders. 

I.  In  purely  functional  cardiac  disorders,  the  sym- 
ptoms, whether  serious  or  the  reverse,  are  never  constant 
for  any  length  of  time.  In  organic  cases  this  con- 
stancy is  the  rule,  though  the  severity  of  the  symptoms 
necessarily  varies  very  considerably  from  time  to  time. 
When,  therefore,  the  signs  of  cardiac  disorder  are 
always  discoverable,  the  idea  of  a  functional  origin  must 
be  excluded. 


FUNCTIONAL  CARDIAC  DISORDERS.  355 


2.  When  symptoms  become  developed  in  other  organs 
as  a  secondary  result  of  the  cardiac  disorders^  we  may 
be  sure  that  organic  derangement  is  present.  Among 
other  symptoms  of  such  import  are  oedema,  ascites, 
venous  congestion,  pulmonary  haemorrhage,  and  albu- 
minuria. As  a  matter  of  course,  increased  dulness  on 
percussion,  and  murmurs  of  certain  kinds,  especially 
when  persistent  and  not  occurring  in  anaemic  subjects, 
are  indicative  of  structural  changes.  Murmurs  due  to 
functional  causes  will  be  afterwards  referred  to. 

3.  The  effect  of  exercise  sometimes  serves  to  dis- 
tinguish functional  from  organic  disorders.  As  a  general 
rule,  the  symptoms  of  the  latter  are  aggravated  by  move- 
ment, especially  if  violent;  in' functional  disorders  in 
general  this  effect  is  by  no  means  constant,  and  is  some- 
times  altogether  absent.     In  anaemic  cases,  however, 

movement  is  very  apt  to  induce  and  to  aggravate  palpi- 
tation, while  rest  and  quiet  have  a  contrary  effect.  The 
discovery  of  the  exciting  cause  may  aid  in  explaining  the 
nature  of  the  disease,  and  if  the  symptoms  cease  when 
the  cause  is  removed,  the  inference  is  unavoidable  that 
they  are  of  a  functional  nature.  Thus  the  immoderate 
use  of  alcohol,  tea,  and  tobacco  is  a  potent  cause  of 
palpitation,  which  often  ceases  when  the  habits  are  dis- 


356  FUNCTIONAL  CABBIAC  DISORDERS. 

continued.  Under  such  circumstances  there  could  be 
little  doubt  as  to  the  nature  of  the  symptom. 

The  symptoms  of  functional  disorders  of  the  heart 
appear  as  alterations  either  in  the  movements  or  the 
sensations  of  the  organ.  Derangement  of  movement 
takes  two  principal  forms.  In  the  first  of  these  the 
heart  is  excited  or  irritated,  and  beats  more  strongly  and 
frequently  than  natural ;  this  condition  is  included  under 
the  term  palpitation.  In  the  second  form,  of  which 
syncope  or  faintness  is  the  type,  the  heart  either  beats 
feebly  or  almost  ceases  to  act. 

Of  cardiac  disorders  of  sensation,  angina  pectoris,  or 
neuralgia  of  the  heart,  includes  all  the  symptoms  of 
functional  affection  in  which  pain  is  a  prominent  feature, 
and  this  latter  may  be  associated  with  decreased  or  in- 
creased action  of  the  organ.  In  most  of  these  func- 
tional disorders  motor  and  sensory  disturbances  are 
variously  combined.  Disturbances  of  rhythm  in  the 
forms  of  intermissions  and  irregularity  are  not  unfre- 
quent  symptoms  of  functional  disorders.  Intermission 
IS  mostly  of  functional  origin  ;  irregularity  is  sometimes 
observed  in  dyspepsia,  but  is  more  often  associated 
with  organic  mitral  disease.  With  regard  to  their  causa- 
tion  in  general,  it  may   be  stated  that  functional  dis- 


FUNCTIONAL  CARDIAC  DISORDERS.  357 


turbances  of  the  heart's  action  may  be  caused  by  any- 
thing which  interferes  with  the  normal  development  or 
character  of  its  muscular  walls  or  the  healthy  condition 
of  the  blood  passing  through  it,  or  by  interference,  direct 
or  indirect,  with  the  functional  activity  of  its  nervous 
supply.     The  muscular  contraction  and  expansion    of 
the  heart,  together  with  the  regularity  of  its  beat  or 
rhythm,  depend  upon  the  agency  of  the  cardiac  ganglia, 
the  sympathetic  and   pneumogastric  nerves,  and  these, 
together   with    the   muscular    walls,    require    for   their 
normal  action  an  adequate  supply  of  healthy  blood.    The 
action  of  the  heart  may  be  indirectly  disturbed  by  reflex 
action  through  the  nervous  system,  as  in  dyspepsia, 
intestinal  irritation^  and   mental   emotion,  and   may  be 
directly  affected  through  the  passage  of  blood  either  too 
rich  or  too  poor   in   fibrine  and  red  corpuscles.      All 
such    conditions    may    cause    palpitation    or    irregular 
action,  accompanied,  or    not,  by   a    bruit.     Errors    in 
diet,    excessive    smoking,    over-exertion,    and    mental 
shock  are  amongst  the  most  frequent  exciting  causes  of 
functional  disturbances  of  the  heart. 

Dr.  Shapter  classifies  the  predisposing  causes  as 
follows: — "  (i).  Those  conditions  acting  through  or 
upon  the  nervous  system,  such  as  the  general  exhaus- 


3S8  FUNCTIONAL  CABJDIAC  DISOEDEES. 

tion  of  the  nervous  systein,  all  forms  of  reflex  irrita- 
tion, venereal  excesses,  vain  longings,  purposeless 
occupations  and  amusements,  protracted  mental  exer- 
cise, abstinence  from  adequate  repose,  etc.  (2).  Those 
conditions  acting  upon  the  general  blood  supply  of  the 
body,  and  consequently  affecting  the  special  blood  sup- 
ply of  the  heart,  such  as  the  turgid  and  plethoric  states 
of  gross  feeders,  depraved  states  caused  by  bad  and  de- 
ficient diet,  and  all  forms  of  blood  disorders,  as  anaemia, 
gout,  scurvy,  etc.  To  these  may  be  added  the  special  tem- 
perament and  personal  peculiarities  of  the  individual."  * 
When  palpitation  and  disturbance  are  caused  by  over- 
action  and  increased  impulse  of  the  heart  in  nervous  or 
plethoric  subjects,  other  symptoms  are  often  superadded, 
such  as  giddiness,  rushing  of  blood  to  the  head,  violent 
pulsation  of  the  carotids,  a  feeling  of  choking  and 
faintness,  vi^ith  clammy  hands  and  cold  perspiration, 
and  there  is  frequently  irregularity  of  the  heart's  action, 
with,  in  neurotic  patients,  an  occasional  reduplication 
of  the  second  sound,  which  seems  peculiar  to  these 
cases.  These  effects  are  usually  the  result  of  venereal 
excesses,  errors  in  diet,  or  too  little  out-door  exercise, 

*  "  Functional  Disorders  of  the  Heart." — "  Quain's  Diet,  of  Medicine.''' 


FUNCTIONAL  CARDIAC  DISORDERS.  359 

and  when  associated  with  an  irregular  action  of  the 
heart  it  is  very  difficult  to  make  the  patient  take  com- 
fort and  believe  that  he  is  not  the  victim  of  organic 
disease,  especially  should  the  system  be  further  depressed 
by  praecordial  pain. 

When    the  heart's  action   is   affected,  and   there   is 
diminished   impulse  with  no  sign  of  organic   change, 
the  symptoms  are  evidenced  by  much  depression  and 
mental  anxiety.      Faintness  is  often  experienced,  and 
there  may  be  flatulence  or  other  symptoms  of  dyspepsia. 
In  a  case  recently  under  my  care,  the  patient,  a  gentle- 
man   aged    42,    of    sedentary   habits,   had   suffered  for 
some     months    from    irregular    action    of    the    heart, 
together  with  occasional  attacks  of  palpitation.    During 
these  paroxysms  there  was  much  praecordial  pain  and  a 
sense  of  impending  death  ;  his  hands,  feet,  and  body 
generally  became  cold   and   clammy,  and  the  forehead 
was  bedewed  with  cold  perspiration.     These  paroxysms 
would  last  from  five  minutes  to  two  hours,  and  occurred 
at  intervals  of  10  to  20  days,  and  alw'ays  were  induced 
by  smoking  or  sexual  intercourse.     Some  months  ago  I 
had  a  similar  case  under  my  care.     The  subject  was  a 
boy,  aged  14,  who  had  at  an  early  age  contracted  the  habit 
of  masturbation.     The  symptoms  in  this  case,  though 


360  FUNCTIONAL  CAJRDIAC  DISORDERS. 

much  less  urgent,  were  none  the  less  marked.  The 
practical  lesson  to  be  drawn  from  these  and  similar 
cases  is  the  absolute  necessity  of  getting  a  candid  and 
complete  history  of  the  habits  of  life  and  surroundings 
of  the  patient  before  prescribing  any  special  form  of 
treatment. 

Functional  disturbances  of  the  heart  are  frequently 
associated,,  as  before  mentioned,  with  inorganic 
bruits  or  murmurs.  They  are  basic  and  always  sys- 
tolic, the  sounds  being  generally  conducted  in  the 
course  of  the  great  vessels ;  they  are  rarely  heard  at  the 
apex.  Murmurs  of  this  character  occur  especially  in 
chlorosis  and  anaemia^  and  are  accompanied  usually  by 
palpitation,  which  may  persist  after  the  bruit  has  ceased 
to  be  evident.  In  50  cases  of  both  sexes  which  I 
have  noted,  12  had  continued  palpitation  for  some 
months  after  the  bruit  had  ceased  ;  nine  of  these  cases 
were  young  girls  or  women  of  more  or  less  hysterical 
character^  but  the  remaining  three  were  in  men  leading 
sedentary  and  a*nxious  lives,  not  given  to  dietetic  or 
venereal  license.  I  see  many  cases  of  both  sexes,  and  of 
every  variety  of  age,  who  present  these  murmurs,  all  of 
which  are  wont  to  disappear  more  or  less  readily  under 
treatment,  leaving  no  morbid  results  whatever. 


FUNCTIONAL  CARDIAC  BISOEDERS.  361 

Cardiac  exhaustion  often  occurs  as  a  result  of  worry, 
overwork,  late  hours,  or  deficient  nourishment,  and  is 
characterized  by  a  weakened  impulse  with  a  rapid  pulse. 
In  these  cases  the  slightest  exertion  causes  increased 
rapidity  and  breathlessness,  but  without  any  evidence 
of  valvular  disease.  Dr.  Hartshorne  says  :*  "In  U.S. 
General  Hospitals  during  the  Civil  War,  under  my  own 
observation,  as  well  as  that  of  other  practitioners,  quite 
•a  number  of  cases  of  soldiers  were  presented  who  were 
rendered  unfit  for  duty  by  heart  symptoms,  and  yet 
without  signs  of  valvular  or  other  organic  disease. 
Careful  investigation  of  these  satisfied  me  that  the 
condition  was  one  of  muscular  exhaustion  of  the  heart." 
The  same  author  says,  "  Heart  starvation  is  probably 
(in  people  who  are  underfed,  overworked,  or  suffering 
from  worry)  often  overlooked  or  mistaken  for  fatty 
degeneration  of  the  heart?"* 

My  experience  entirely  coincides  with  the  opinion 
expressed  by  Dr.  Hartshorne;  I  have  seen  many  cases 
of  the  irritahle  heart  justly  so  named  by  Da  Costa.  I 
may  mention  one  instance.  I  was  consulted  by  a 
medical  man  who  had  had  much  physical  exertion  in  a 

*  *'  Essentials  of  Medicine,"  5  th  Ed.,  p.  253. 


362        THE  NERVES  OF  THE  HEART. 

parochial  practice  in  a  hilly  district  and  had  many  home 
worries  ;  the  evidence  was  conclusive  in  my  opinion 
that  his  cardiac  derangement  was  due  to  muscular 
exhaustion.  Time,  rest  in  a  bracing  air,  with  a  nutri- 
tious dietary,  is  in  such  cases  all  that  is  required  for 
apparently  complete  restoration  to  health. 

Fothergill  says  that  palpitation  is  the  evidence  of 
muscular  inability.  Neuroses  of  the  heart  is  the  term 
Niemeyer  applies  "to  these  forms  of  perversion  of  its 
action  or  abnormity  of  its  sensations  which,  without 
depending  upon  any  structural  change,  arise  either 
without  perceptible  cause  or  else  upon  occasions  which 
in  most  persons  would  not  give  rise  to  any  functional 
disturbance." 

In  order  to  understand  some  portion  of  the  mechanism 
of  cardiac  neuroses,  it  is  necessary  to  inquire  into  the 
sources  whence  the  heart  derives  its  nerves.  A  very 
simple  experiment  proves  that  the  rhythmical  move- 
ments depend  upon  the  presence  of  ganglia  situated 
within  the  heart  itself,  for  when  the  organ  is  removed 
from  the  body,  or  when  all  the  nerves  passing  to  it  are 
divided,  regular  contractions  go  on  for  some  time. 
This  phenomenon  is  best  seen  in  the  heart  of  a  fish  or 
turtle ;  contractions  go  on  for  hours  after  removal,  and 


THE  NERVES  OF  THE  HEART.  3(^7, 

even  when  they  appear  to  have  ceased  they  may  1)e 
excited  by  touching  the  surface  with  the  point  of  a 
needle.  Moreover^  the  fact  that  a  regularly-pulsating 
heart  has  been  found  in  anencephalic  monsters  proves 
that  this  organ  is  not  exclusively  or  essentially  depen- 
dent upon  the  central  nervous  system  for  the  continu- 
ance of  its  rhythmical  movements.  In  addition, 
.however^  to  the  rhythmical  movements  of  the  heart,  it 
is  a  matter  of  common  observation  that  its  action  is 
influenced  by  impressions  which  reach  it  from  without^ 
e.g.,  from  the  brain,  abdominal  viscera,  and  limbs,  and 
these  impressions  are  conveyed  to  it  by  the  pneumogas- 
tric  and  sympathetic  nerves. 

The  heart  contains  many  automatic  centres  which  are 
connected  with  each  other  by  nervous  fibres.  The 
dominating  centre,  according  to  Landois,  lies  in. the 
auricles,  and  hence  the  regular  progressive  movement 
usually  starts  from  them.  The  same  author  states  that 
the  auricular  centres  seem  to  be  more  excitable  thgn 
those  of  the  ventricle;  that  all  stimuli  of  moderate 
strength  applied  directly  to  the  heart  increase  the 
frequency  of  the  rhythmical  heart-beats,  whereas 
stronger  stimuli  cause  a  diminution,  and  possibly 
paralysis.     Another  important  point  is  that  the  heart 


364  TSJE  NI^RVES  OF  THE  HEART. 

may  be  excited  from  Its  internal  surface,  and  that  very 
weak  stimuli  suffice  to  produce  this  effect.  A  supply  of 
blood  or  other  similar  fluid  holding  nutritive  materials  in 
solution  is  necessary  for  the  contractions.  It  would 
appear  that  the  presence  of  ganglia  is  not  absolutely 
necessary  for  rhythmical  pulsation,  inasmuch  as  the 
latter  takes  place  in  parts  of  the  heart  devoid  of  these 
structures,  and  direct  stimulation  of  the  muscular  fibres, 
may  cause  the  movements.  The  ganglia  are,  however, 
much  more  excitable  than  the  heart  itself,  and  we  must 
assume  that  they  preside  over  the  rhythmical  movements. 
It  must  be  mentioned  that,  according  to  some  obser- 
vers, the  heart  contains  certain  ganglia  which  exercise 
an  inhibitory  or  restraining  influence. 

The  influence  of  the  pneumogastric  nerve  has  been 
much  disputed,  but  the  main  questions  relating  to  its 
action  may  be  regarded  as  settled.  Experiments  clearly 
prove  that  irritation  of  the  pneumogastric  nerve  weakens 
■oi*  suspends  the  motor  influence,  through  which  other 
nervous  mechanism  causes  the  contractions  of  the  heart. 
The  action  of  the  vagus  is,  therefore,  of  an  inhibitory, 
paralyzing  character ;  the  fibres  charged  with  this  office 
run  originally  in  the  spinal  accessory  nerve.  When  the 
fibres  of  this  latter  have  been  removed  from  the  jugular 


TEE  NERVES  OF  THE  HEART.  365 

foramen^  and  a  few  clays  suffered  to  elapse,  the  nervous 
fibres  supplied  to  the  vagus  in  that  position  undergo 
degeneration  at  their  peripheral  extremities^  and  are 
incapable  of  being  excited  ;  it  is  then  found  that  irrita- 
tion of  the  vagus  on  that  side  has  no  effect  upon  the 
frequency  of  the  cardiac  pulsations^  and  certainly 
does  not  arrest  them. 

When  a  magneto-electric  current  is  applied  to  the 
medulla  oblongata^  the  hearths  action,,  after  a  few  pulsa- 
tionSj  comes  to  a  complete  standstill ;  and  this  condition 
remains  until^as  a  result  of  the  tetanizing,  or  exhaustion 
or  destruction  of  irritability  of  the  nervous  channels^  the 
action  of  the  heart  is  restored.  The  pneumogastric 
nerves  are  the  channels  which  conduct  the  inhibitory 
influence  from  the  medulla  oblongata,  for  if  one  of  these 
be  divided,  and  the  peripheral  end  be  galvanized^  the 
hearths  action  is  arrested  in  diastole.  Irritation  of  one 
nerve  is  sufficient  for  this  effect  to  be  produced^  and  not 
only  the  number  but  the  force  of  the  pulsations  is 
diminished  ;  and  the  arrest  of  the  hearths  action  is  some- 
times brought  about  not  by  increasing  the  pause  be- 
tween  the  pulsations^  but  by  lessening  the  degree  of  the 
contractions.  The  consequent  diminution  of  blood- 
pressure  in  the  arteries  will  thus  have  a  two-fold  origin. 


366        THE  NERVES  OF  THE  HEART. 

Division  of  the  pneumogastric  nerve  is  followed  by 
permanent  increase  in  the  number  of  the  heart's  pulsa- 
tions and  simultaneous  elevation  of  the  blood  pressure 
throughout  the  arterial  system^  and  the  amount  of  work 
done  by  the  heart  is^  therefore,  increased.  The  same 
result  is  witnessed  when  both  spinal  accessory  nerves 
are  removed  from  the  base  of  the  skull,  and  no  further 
effect  is  produced  by  subsequent  division  of  the  vagus. 
It  isj  therefore,  clear  that  those  fibres  of  this  nerve,, 
whose  irritation  causes  arrest  of  the  heart's  action,  are 
the  same  as  those  whose  paralysis  leads  to  an  opposite 
result,  viz.,  to  increased  frequency  and  stretigth  of  action. 

In  addition  to  being  the  channel  for  inhibitory  in- 
fluences, the  pneumogastric  furnishes  sensory  fibres  to 
,  the  heart.  These  form  a  plexus  beneath  the  pericardium; 
when  their  central  portions  are  irritated,  the  heart's 
action  is  retarded  and  the  arterial  blood-pressure  is 
increased.  In  the  natural  state,  the  sensitiveness  of 
the  heart  is  extremely  slight;  signs  of  pain  are  seldom 
elicited  when  the  organ  is  mechanically  irritated.  No 
reflex  movements  follow  irritation  after  both  vagi  are 
divided ;  but  if  one  be  left  intact,  movements  of  this 
character  are  found  to  be  produced. 

The  third  class   of  nerves  connected  with  the  heart 


THE  NERVES  OF  TSE  HEART.  367 

are  those  through  whose  instrumentaHty  its  action  is 
accelerated.  These  are  centrifugal  fibres_,  and  when 
excited,  they  increase  the  number  of  the  pulsations  by 
from  30  to  70  per  cent._,  and  thus  act  as  the  antagonists 
of  the  inhibitory  nerves  just  described.  Some  of  these 
pass^  however_,  with  these  latter  in  the  cervical  portions. 
of  both  vagi,  but  a  still  larger  supply  is  derived  from 
the  branches  of  the  first  thoracic  ganglion  of  the 
sympathetic,,  and  these  take  their  course  to  the  heart 
partly  as  independent  fibres  and  partly  in  connection 
with  branches  of  the  vagus.  The  sympathetic  in  the 
neck  sometimes  gives  oflF  similar  fibres.  The  larger 
portion  of  these  accelerating  nerves  pass  downwards 
from  the  medulla  oblongata  through  the  cervical  and 
dorsal  spinal  cord,  and  thence  to  the  thoracic  sym- 
pathetic^ and  finally  to  the  cardiac  plexus.  The  course 
described  by  these  nerves  is  therefore  loop-shaped,  the 
majority  pass  downwards  in  the  spinal  cord  and  up- 
wards in  the  sympathetic.  Those  fewer  fibres  which 
pass  with  the  vagus  and  the  cervical  sympathetic  do  not 
form  such  loops,  but  they  probably  have  the  same 
origin  as  the  others. 

These  nerves,  by  means  of  vv^hich  the  action  of  the 
heart  is  accelerated^  are  not,  as  a  general   rule,  in  any 


368        THE  NERVES  OF  THE  HEART. 

way  under  the  influence  of  the  will ;  but  some  persons 
possess  the  power  of  voluntarily  rendering  the  heart's 
action  more  frequent.  Such  a  result  is  often  produced 
involuntarily  under  the  influence  of  emotional  causes, 
and  is  due  less  to  diminished  action  of  the  pneumogas- 
trics  than  to  excitement  of  the  "cerebral  centres  of  the 
accelerating  nerves.  These  nerves  and  their  centres  are 
said  to  be  less  easily  excited  and  less  readily  exhausted 
than  all  other  nerves^  and  this  difference  is  very  marked 
when  they  are  contrasted  with  the  vagus.  Their  ex- 
citement increases  the  force  as  well  as  the  frequency  of 
the  heart's  contractions. 

There  is  yet_,  in  some  animals  at  leasts  a  fourth  set  of 
nerves,  by  means  of  which  the  action  of  the  heart  is 
influenced.  These  are  the  so-called  depressor  fibres 
of  the  vagus,  and  in  rabbits  are  derived  from  the 
superior  laryngeal  nerve  and  are  sometimes  increased 
by  a  second  branch  from  the  vagus  itself  and  then 
join  the  cardiac  plexus.  Excitement  of  these  nerves 
is  followed  by  considerable  diminution  of  the  blood- 
pressure  in  the  arteries,  and  this  is  not  the  result 
of  an  impulse  directed  centrifugally  towards  the 
heart,  but  of  one  transmitted  in  a  central  direction  to 
the  medulla  oblongata.     The  diminution  in  pressure  is 


THE  NERVES  OF  THE  HEART.  369 

caused  when  an  induced  current  is  applied  to  the  central 
end  of  the  divided  nerve,  but  no  such  result  follows  the 
application  to  the  peripheral  extremity.  In  order  to 
explain  this  curious  phenomenon  it  is  assumed  that  in  a 
reflex  manner  the  depressor  fibres  lessen  or  abolish  the 
power  of  the  vaso-constrictor  nerves,  and  especially  of 
those  of  the  abdominal  viscera^  and  bring  about  the 
diminution  of  blood-pressure  in  the  arteries  by  facilitating 
the  escape  of  the  blood  into  the  capillaries  and  veins. 
Irritation  of  the  central  portion  of  these  nerves  excites 
the  vagus  centre  in  the  medulla  oblongata,  and 
diminished  frequency  of  the  cardiac  contractions  is  the 
result^  which,  however,  ceases  when  both  vagi  are 
divided  below  the  origin  of  the  depressor  nerves.  It  is 
doubtful  whether  this  second  reflex  action  of  the 
depressors,  which  they  share  with  many  sensory  nerves 
of  the  skin  and  viscera,  is  peculiar  to  them,  or  whether  it 
is  derived  from  other  sensory  nerves  which  are  as- 
sociated with  them. 

The  following  extract  from  Dr.  Carpenter's  "  Prin- 
ciples of  Human  Physiology  '^  gives  a  short  summary 
of  the  circumstances  affecting  the  frequency  of  the 
heart's  action.  '^^  The  heart  not  only  possesses  an 
internal  system  of  ganglia  and  nerves,    by    which    its 


370       TRE  NERVES  OF  THE  HEART. 

movements  can  be  maintained  and  regulated  for  some 
time  after  excision  from  the  body,  but  it  is  also  under 
the  control  of  centres  situated  in  the  medulla  oblongata, 
and,  as  there  is  reason  for  believing  that  there  are  both 
•accelerating  and  inhibitory  centres  in  the  heart  and  in 
the  medulla^  it  is  obvious  that  great  difficulty  must 
exist  in  determining  the  cause  of  any  particular  varia- 
tion in  the  frequency  of  its  beats  that  may  be  observed. 
We  have^  however,  evidence  that  the  heart  may  be 
influenced  — 

"A.  By  conditions  affecting  the  intra-cardiac  motor 
ganglia  which  may  be  (i)  excited  and  the  frequency  of 
the  pulsations  increased ;  (a)  by  heat;  [h)  by  mechanical, 
chemical,  and  electrical  excitation;  (c)  by  increased 
blood-pressure,  which  is  essentially  a  mechanical  irritant; 
[d)  by  various  poisons  ;  or  (3)  depressed,  and  the  pulsa- 
tions lowered ;  (a)  by  cold ;  {h)  by  diminished  blood- 
pressure  ;   [c)  by  certain  poisons,  as  chloral. 

"B.  By  conditions  affecting  the  intra-ca^-diac  inkihitory 
ganglia,  these  being  stimulated,  and  the  heart  slowed  or 
stopped  in  diastole  by  certain  poisons  (muscarin),  and 
paralyzed  by  others. 

''  C.  By  conditions  affecting  the  intra-cardiac  acceler- 
ator ganglia  leading  to  increased  frequency  of  action. 


THE  NERVES  OF  THE  HEART.  371 

At  present  these  cannot  be  satisfactorily  distinguished 
from  those  affecting  the  intra-cardiac  motor  ganglia. 

''  D.  By  conditions  affecting  the  cardiac  inhibitory 
centres  in  the  medulla  oblongata,  snch  as  increased 
blood-pressure^  which  acts  directly  upon  them,  or  by 
irritation  of  the  depressor  nerve,  or  of  various  other 
sensory  nerves  which  act  upon  them  in  a  reflex  manner, 
or  by  the  actions  of  poisons  (digitalis),  all  of  which 
excite  these  centres  and  cause  slowing  of  the  heart's 
action. 

''^E.  By  certain  conditions  affecting  the  accelerator 
centres  in  the  medulla,  as  diminished*  blood- pressure, 
mental  processes,  the  action  of  poisons.  They  may 
also  probably  be  excited  in  a  reflex  manner.  It  will  be 
seen  from  the  above  that  certain  conditions,  increased 
blood-pressure,  for  example,  exert  a  double  action  on  the 
cardiac  nerves.  On  the  one  hand,  it  excites  the  heart 
to  increased  frequency  of  action  by  direct  irritation  of 
its  motor  ganglia  through  filaments  distributed  to  the 
endocardium;  on  the  other  hand,  it  stimulates  the 
vagal  centres  in  the  medulla  and  thus  causes  slowing  of 
the  heart,  the  actual  result  in  any  given  case  bein"" 
dependent  upon  the  preponderating  influence  of  the 
cardiac  motor  or  medullary  inhibitory  centres.     Usually 


572        TEE  NERVES  OF  THE  HEART. 

the  medullary  centres  are  strongest^  and  increased 
blood-pressure  causes  slowing  of  the  heart;  but  if  the 
vagi  be  divided  so  that  they  can  no  longer  act  upon  the 
heart,  increased  blood-pressure  stimulates  the  heart  to 
more  rapid  action/' 


CHAPTER    II. 

PALPITATION  OF  THE  HEART. 


Cardiac  Palpitation,  Description  of — General  Symptoms — Alter- 
ation IN  Sounds  of  Heart  and  in  Pulse — Condition  of  the 
Respiration  and  of  the  Features — Subjective  Sensations — 
Duration  of  Attacks — Causes  of  Palpitation — Nervous  and 
Toxic  Causes — Exhaustion — Reflex  Irritation — Exciting 
Causes  —  Diagnosis  —  Prognosis  —  Treatment  —  Relief  of 
Paroxysms  and  Prevention  of  Recurrence — Position,  Cold  to 
Chest,  Medicines — Treatment  of  Nervous  Subjects — Treat- 
ment of  Palpitation  Due  to  Indigestion  and  Gout — During 
the  Intervals — Various  Points  to  be  Attended  to. 

This  term  is  used  to  signify  attacks  in  which  the  heart 
beats  with  increased  frequency^  and  generally  with  in- 
creased force.  Pulsations  of  this  kind  are  often  excited 
in  a  perfectly  healthy  individual  by  incidents  and 
amotions  of  every-day  life,  and  under  such  circum- 
stances they  are,  of  course,  not  to  be  considered  as 
morbid.  It  is  only  when  the  attacks  of  palpitation  are 
very  frequent  or  very  easily  excited  that  they  constitute 
disorder.  They  are,  of  course,  a  common  symptom  of 
organic  cardiac  lesions,  but  they  are  still  more  frequent 
when  no  such  changes   exist.      Attacks  of  palpitation 


374  SYMPTOMS  OF  PALPITATION. 

alternate  with  the  normal  movements;  they  may  last 
for  a  few  minutes  or  for  some  hours.  The  frequency 
with  which  they  occur  varies  greatly ;  in  some  cases 
scarcely  a  day  passes  without  one  or  more  j  in  others 
there  may  be  weeks'  or  months  between  the  attacks. 

A  severe  attack  of  palpitation  is  often  ushered  in  by 
peculiar  sensations  in  the  cardiac  region.  The  patient 
experiences  a  feeling  of  indescribable  discomfort ;  the 
heart  appears  to  be  beating  irregularly  and  with  diffi- 
culty_,  or  as  if  it  could  go  on  no  longer^  or  there  may  be 
a  feeling  as  if  something  had  given  way  in  the  heart. 
During  the  attack  the  sensations  of  distress  and  oppres- 
sion continue,  and  difficulty  of  breathing  is  often 
superadded.  The  countenance  is  indicative  of  the  feel- 
ings of  the  patient ;  the  forehead  may  be  covered  with 
cold  perspiration.  Faintness  is  sometimes  experienced, 
and  headache,  noises  in  the  ears,  and  a  feeling  of  giddi- 
ness are  not  unfrequent.  In  some  cases  of  palpitation, 
with  irregularity  of  action,  the  patients  complain  of 
pain  in  the  post-occipital  region,  where  the  arteries 
enter  the  skull,  and  occurring  at  the  time  of  the  cardiac 
intermissions. 

On  examining  the  heart  during  an  attack  of  palpita- 
tion its  action  is  found  to  be  tumultuous,  abnormally 


SYMPTOMS  OF  PALPITATION.  375 

frequent^  and  perceptible  over  a  large  surface.  If  the 
attack  lasts  for  any  time^  irregularity  is  generally 
observed,  and  the  sounds  of  the  heart  undergo  various 
modifications.  The  first  sound  often  has  a  metallic 
tone,  and  can  be  heard  at  some  distance  from  the  chest. 
The  second  sound  is  sometimes  so  faint  that  it  may 
appear  to  be  absent;  this  change  results  from  the  in- 
sufficient quantity  of  blood  contained  in  the  aorta  and 
pulmonary  artery;  it  is  more  and  more  marked  in 
proportion  to  the  rapidity  of  the  movements.  Some- 
times the  pauses  between  the  sounds  of  the  heart 
become  equalized_,  so  that  the  comparatively  long 
interval  which  follows  the  second  sound  is  very  much 
shortened.  The  carotids  pulsate  violently,  and  on 
placing  a  stethoscope  over  them  a  systolic  murmur  is 
frequently  audible.  When  the  attacks  of  palpitation 
last  for  any  time  swelling  and  pulsation  in  the  veins  of 
the  neck  are  generally  perceptible. 

The  pulse  at  the  wrist  is  frequent,  hard,  and  full, 
less  often  soft  and  small,  but  irregularity  is  usually 
noticeable.  With  regard  to  frequency,  it  is  difficult  to 
assign  any  limits;  as  many  as  200  pulsations  have  been 
counted  in  the  minute.  In  examining  a  pulse  of  this 
character  it  is  well  to  count  by  fives,  and  then  to  add 


376  SYMPTOMS  OF  PALPITATION. 


these  up  ;  by  this  plan  mistakes  are  less  likely  to  happen 
than  if  the  attempt  be  made  to  count  by  consecutive 
numbers.  It  is  also  well  to  estimate  the  number  of  the 
heart's  contractions  by  means  of  auscultation^  for  during 
such  rapid  movements  of  the  heart  the  pulse-wave  will 
not  alwavs  extend  to  the  radial  arteries,  and  hence  it 
happens  that  the  pulse  there  is  often  intermittent. 

In  attacks  of  palpitation  the  respiration  is  generally 
impeded,  the  patients  complaining  of  the  sensation  of 
want  of  breath.  The  breathing  is  frequent  and  irregular, 
and  liable  to  be  interrupted  by  deep  and  sighing  inspira- 
tions. This  difficulty  of  breathing  is  aggravated  when 
the  patient  lies  down,  but  is  relieved  by  raising  the 
thorax,  or  by  adopting  a  sitting  posture.  In  severe 
attacks  speaking  becomes  difficult,  and  the  voice  may  be 
reduced  to  a  whisper.  Sometimes  there  is  difficulty  in 
swallowing,  and  pain  in  the  stomach  with  swelling  of 
the  abdomen.  The  features  are  always  disfigured;  the 
face  is  red  and  generally  covered  with  perspiration ; 
more  rarely  the  face  and  extremities  are  cold,  moist, 
pale,  or  livid.  Elevation  of  temperature  is  generally 
observed. 

The  duration  of  the  attack  varies.  In  some  cases 
it  passes  off  almost  suddenly  ;  in  others  it  subsides  very 


CA  USES  OF  PA  LP  IT  A  TION.  .3  7  7 

gradually.  After  its  disappearance  the  patients  feel 
very  anxious  lest  it  should  recur.  Sudden  subsidence 
of  the  attack  is  sometimes  associated  with  vomiting, 
eructations,  or  free  action  of  the  bowels. 

It  is  worthy  of  note  that  there  are  some  cases  of 
palpitation  of  the  heart  in  which  the  symptoms  are 
almost  entirely  subjective.  The.  patient  relates  many  of 
the  details  as  given  above,  but  no  objective  disorder  is 
decidedly  manifested.  Careful  examination  may,  how- 
ever, detect  some  irregularity  of  the  pulse  during  the 
attacks. 

Attacks  of  palpitation  of  the  heart  may  be  induced 
by  a  great  variety  of  causes,  the  majority  of  these  acting 
on  the  nervous  system.  The  attempt  has  been  made  to 
divide  these  causes  into  several  categories  according  as 
the  pneumogastric  nerve,  the  sympathetic,  the  brain,  or 
the  spinal  cord  is  the  seat  of  excitement.  Such  a 
classification  is,  however,  scarcely  possible,  but  in  a 
general  way  it  may  be  stated  that  in  most  cases  of 
palpitation  the  condition  is  that  of  paralysis  of  the 
inhibitory  nerve  fibres  of  the  heart,  which  are  supplied 
by  the  pneumogastric,  and  less  commonly  one  of 
irritation  of  the  excito-motor  nerves  from  the  sym- 
pathetic.    For    clinical    purposes    it   is    convenient    to 


378  CAUSES  OF  PALPITATION. 

divide  attacks  of  palpitation  into  two  classes^  the  first 
containing  those  that  are  due  to  nervous  causes,  and 
the  second,  those  in  which  toxic  matters  are  present  in 
the  blood. 

Nervous  causes  of  palpitation,  the  results  of  the  con- 
dition of  the  cerebrum,  are  of  every-day  occurrence,  and 
are  typified  by  the  various  forms  of  emotional  excite- 
ment caused  by  joy,  grief,  shock,  anxiety,  and  the  like. 
The  effect  of  the  imagination  in  producing  palpitation 
is  sometimes  very  marked ;  medical  students,  for 
example,  in  studying  diseases  of  the  heart  for  the  first 
time,  often  suffer  from  tumultuous  and  irregular  action 
of  the  organ  in  question,  and  imagine  that  they  are  the 
subjects  of  heart  disease.  I  am  acquainted  with  many 
medical  practitioners  of  nervous  temperament,  who,  as 
a  result  of  hard  work,  suffer  from  attacks  of  palpitation 
and  intermittency  of  the  heart's  action,  and  think 
themselves  the  victims  of  organic  disease.  All  the 
symptoms,  however,  subside  after  a  few  days'  rest 
and  change.  Some  persons  have  the  power  of  volun- 
tarily increasing  the  frequency  of  the  heart's  contrac- 
tions. 

Nervous  palpitation  is,  of  course,  a  common  symptom 
both   of  organic  and   of  functional  nervous  disorders. 


CAUSES  OF  PALPITATION.  379. 

Thus  it  often  occurs  in  connection  with  congestion, 
haemorrhage,  softenings,  and  tumours  of  the  brain  and 
spinal  cord.  Tumours  in  the  neck  may  cause  attacks 
of  palpitation  by  interfering  with  the  pneumogastric  or 
sympathetic  nerv^es.  In  a  case  recorded  by  myself  in 
the  Archives  of  Laryngology ,  Vol..  ii._,  No.  3,  a  bony 
growth  from  the  last  cervical  vertebra  was  the  cause 
of  attacks  of  palpitation  and  of  spasm  in  the  throat. 
Various  conditions  of  exhaustion  are  especially  apt 
to  be  accompanied  by  palpitation  of  the  heart  ; 
thus  attacks  are  common  in  cases  of  hysteria,  spinal 
irritation,  and  neurasthenia.  They  are  also  frequent 
results  of  mental  strain,  of  excesses  of  all  kinds, 
of  chlorosis,  of  loss  of  blood,  and  of  severe  and 
exhausting  diseases.  Persons  who  work  for  many 
hours  in  small  and  ill-ventilated  rooms  and  take  an 
insufficient  amount  of  nourishment  frequently  suffer 
from  palpitation. 

Reflex  irritation  is  a  common  and  important  cause  of 
palpitation.  It  is  a  matter  of  every-day  experience  that 
attacks  are  often  due  to  a  disordered  state  of  the 
stomach,  either  a  mere  temporary  indigestion,  or  a 
more  permanent  and  serious  condition.  I  have  met 
with  several  cases  in  whom    palpitation  and  signs    of 


38o  CAUSES  OF  PALPITATION. 

violent  cardiac  disturbance^  occurring  during  the  night, 
and  waking  the  patients  from  their  sleep,  were  caused 
by  two  or  three  glasses  of  cheap  sour  claret  taken  at 
dinner.  In  some  persons  certain  articles  of  food,  even 
when  taken  in  moderation^  are  sufficient  to  induce  an 
attack.  In  all  these  cases  the  pneumogastric  is  the 
nerve  through  which  the  irritation  is  propagated. 
Other  causes  of  a  reflex  nature  are  constipation,  worms 
in  the  intestines,  and  haemorrhoids  ;  in  the  latter  case 
the  attacks  are  wont  to  come  on  after  the  cessation  of 
haemorrhage.  In  the  case  of  a  gentleman  whom  I  have 
been  recently  attending  the  attacks  of  palpitation  have 
quite  ceased  since  he  has  undergone  a  successful  opera- 
tion for  the  radical  cure  of  piles.  Disorders  of  the 
uteru.s  and  ovaries  are  especially  liable  to  cause  palpitation 
and  other  symptoms  of  hysteria,  and  attacks  are  some- 
times observed  in  connection  with  renal  calculi. 

Attacks  of  palpitation  due  to  toxic  causes  are  very 
frequently  seen.  Thus  they  often  follow  the  immoderate 
and  even  the  moderate  use  of  alcohol,  tobacco,  tea,  and 
coffee.  Certain  peculiarities  are  sometimes  observed  ; 
thus  I  have  met  with  several  cases  of  middle-aged  men 
and  women  in  whom  severe  palpitation,  with  an 
intermittent  pulse,  was  always  caused  by  taking  a  cup 


CAUSES  OF  PALPITATION.  381 

of  tea  in  the  early  morning.  When  cocoa  was 
substituted  there  were  no  such  effects,  and  the  tea  could 
be  taken  at  other  times  in  the  day  without  causing  dis- 
comfort. The  palpitation  in  gouty  subjects  is  due  in 
the  first  place  to  irritation^  propagated  from  the  stomach, 
and,  secondly,  to  the  presence  of  an  abnormal  amount 
of  uric  acid,  which  acts  as  a  direct  irritant  to  the  heart. 
Palpitation  of  the  heart  occurs  in  persons  of  all  ages. 
In  children  it  is  most  common  during  the  educational 
period,  and  is  due  to  immoderate  application  to  studies^ 
ambition,  and  anxiety.  Other  causes,  such  as  debility, 
indigestion,  and  worms,  are  often  present.  In  all  cases 
the  attacks  are  wont  to  come  on  spontaneously;  some- 
times, indeed,  they  occur  when  the  patient  is  in 
bed  and  arouse  him  from  a  deep  sleep.  In  other 
cases  they  are  the  direct  and  immediate  consequences  of 
bodily  or  mental  exertion.  I  have  recently  attended  a 
gentleman,  aged  45,  married  {with  a  family,  and  not 
given  to  sexual  excesses),  in  whom  palpitation  always 
occurs  after  four  or  five  hours'  continuous  mental  work, 
but  not  before  that  time,  and  ceases  when  the  occupa- 
tion is  relinquished.  Among  other  causes  of  attacks 
may  be  mentioned  intestinal  disorders,  menstrual 
irregularities,  exposure  to  cold,  or  to  heat,  and  the  like. 


382  DIAGNOSIS  OF  PALPITATION. 

Some  persons  have  an  attack  of  palpitation  if  they  lie 
on  their  left  side. 

The  diagnosis  of  palpitation  of  the  heart  is  seldom  a 
matter  of  much  difficulty.  Bearing  in  mind  the  fact 
that  similar  attacks  often  occur  in  cases  of  organic 
disease^  the  actual  condition  of  the  heart  is  the  point  to  be 
determined.  Valvular  diseases  will_,  of  course,  be  accom- 
panied by  the  peculiar  murmurs,  but  abnormal  sounds 
are  not  infrequent  in  nervous  palpitation  during  a  severe 
attack.  The  murmur  is,  however,  always  systolic  in 
character,  and  is  never  associated  with  signs  of  dilata- 
tion and  hypertrophy.  In  chlorotic  and  anaemic  cases 
a  permanent  systolic  murmur  is  often  present,  but  the 
detection  of  the  bruit  de  diable  and  the  improvement  which 
almost  invariably  takes  place  under  treatment  will  indicate 
the  nature  of  the  case.  Pericarditis  is  often  accompanied 
with  severe  attacks  of  palpitation,  but  the  cause  of  the 
symptoms  can  hardly  be  mistaken.    . 

The  prognosis,  of  course,  depends  upon  the  cause  of 
the  symptom  ;  in  many  cases  not  only  can  the  attacks 
be  relieved,  but  their  recurrence  can  be  prevented  by 
appropriate  treatment.  In  cases  in  which  the  cause 
cannot  be  dealt  with  more. or  less  amelioration  can 
almost  always  be  promised,  but  the  patients  are  apt  to 


TREATMENT  OF  PALPITATION.  383 

become  very  low-spirited  and  even  hypochondriacal. 
However  distressing  the  attacks  may  be^  a  fatal  termina- 
tion need  scarcely  ever  be  apprehended  in  the  absence  of 
organic  disease.  In  elderly  subjects_,  however^  with 
degeneration  of  the  cerebral  arteries,  there  is  risk  of 
rupture  of  vessels  and  haemorrhage  during  attacks  of 
palpitation.  The  heart  itself  is  liable  to  become  affected 
in  the  course  of  time_,  as  a  result  of  the  over-exertion. 
Hypertrophy  of  the  organ  is  generally  due  to  the  exist- 
ence of  obstruction^,  either  in  the  valves  or  in  the 
vessels,  but  in  a  less  numerous  class  of  cases  hyper- 
trophy is  the  result  of  increased  cardiac  action  without 
increased  resistance.  Niemeyer's  statement  on  this 
subject  has  been  already  referred  to.  ^^  In  many  per- 
sons we  are  forced  to  assume  the  existence  of  an 
exalted  irritability,  an  erythism  of  the  nervous  system, 
particularly  of  the  nerves  of  the  heart,  so  that  trifling 
causes  serve  to  excite  and  strengthen  its  action.''- 

Treatment.  In  the  treatment  of  persons  subject  to 
attacks  of  palpitation  of  the  heart  there  are  two  princi- 
pal objects  to  be  fulfilled;  the  first  being  to  relieve  or 
cut  short  the  paroxysms,  and  the  second  to  prevent 
their  recurrence.  To  afford  relief  during  attacks  the 
patient  should  be  placed  in  a  semi-recumbent  posture. 


384  TREATMENT  OF  PALPITATION. 

with  the  chest  raised  and  the  clothes  loosened  about 
the  neck  and  chest;  fresh  air  should  be  freely  admitted. 
In  some  cases  relief  is  obtained  by  the  application  of 
cold  to  the  chest_,  or  by  sucking  pieces  of  ice.  Pres- 
sure on  the  sympathetic  and  pneumogastric  in  the  neck 
and  on  certain  spots  in  the  abdomen  has  been  known 
to  cut  short  attacks. 

With  regard  to  medicines^  the  subcutaneous  injec- 
tion of  morphine  often  has  the  effect  of  relieving 
palpitation,  but  its  use  requires  caution.  Other  reme- 
dies of  the  same  character,  such  as  chloral_,  tincture  of 
henbane,  aether,  and  belladonna  are  also  efficacious,  but 
there  are  no  special  indications  for  their  use.  In  cases 
in  which  the  palpitation  is  the  result  of  shock,  a  full 
dose  of  the  bromide  of  ammonium  will  generally  allay 
the  discomfort. 

In  nervous,  hysterical,  and  hypochondriacal  subjects, 
relief  will  often  be  afforded  by  the  nervine  stimulants, 
as  asafcetida  and  valerian,  camphor,  and  preparations  of 
ammonia  and  aether.  Aromatics  combined  with  antacids 
are  sometimes  useful,  inasmuch  as  they  help  the  expul- 
sion of  flatus  and  correct  acidity.  With  this  view  a 
teaspoonful  of  the  compound  tincture  of  lavender,  or 
of  the  compound  spirit  of  horse-radish,  may  be  given 


TREATMENT  OF  PALPITATION.  385 

in   combination    with    half    the    quantity   of   aromatic 
spirit  of  ammonia. 

When  an  overloaded  stomach  is  suspected  to  be  the 
cause  of  the  attack,  an  emetic  dose  of  ipecacuanha  will 
be  the  best  remedy.  The  hypodermic  injection  of 
gr.  xV  of  the  hydrochlorate  of  apomorphine  may  be 
used  instead.  For  attacks  of  palpitation  in  gouty  sub- 
jects, emetics  are  not  advisable  unless  there  be  ineffec- 
tual attempts  to  vomit.  An  alkaline  draught  with  a 
little  aether  will  serve  to  quiet  the  heart. 

In  order  to  prevent  the  recurrence  of  the  paroxysms, 
the  treatment  must  be  directed  towards  the  removal  of 
the  cause  or  modifying  its  operation.  Hygienic  measures 
of  all  kinds  must  first  be  thought  of.  Thus  the  diet 
must  be  easily  digestible  and  adapted  in  quantity  to  the 
patient^s  condition.  Distension  of  the  stomach  and 
excesses  of  all  kinds^  especially  in  the  direction  of 
alcoholic  drinks,  tea,  coffee,  and  tobacco  must  be 
scrupulously  avoided ;  moderate  exercise  in  the  open  air 
and  attention  to  the  skin  will  tend  to  lessen  the  irrita- 
bility of  the  nervous  centres.  Constipation,  if  present, 
must  be  dealt  with  by  laxatives  and  mild  purgatives. 
"With  regard  to  medicines  having  a  specific  action  on 
the  heart,  digitalis   and  the  bromide  of  potassium  are 

25 


SS6  TEJEATMUNT  OF  PALPITATION. 

likely  to  be  serviceable,  either  separately  or  in  combina- 
tion. The  digitalis  should  be  given  in  small  doses 
(ttt  v-x  of  the  tincture)  three  times  a  day,  and  the 
effects  carefully  u^atched.  The  bromide  of  potassium 
may  in  debilitated  cases  be  combined  with  a  little  citrate 
of  iron  and  ammonia.  When  the  attacks  come  on  at 
night  it  is  well  to  apply  some  belladonna  liniment  to 
the  left  side  of  the  chest  before  going  to  bed.  Should 
there  be  praecordial  pain,  chloroform  liniment,  sprinkled 
on  spongio-piline,  and  applied  to  the  surface  for  half-an- 
hour,  will  generally  give  relief.  In  many  cases  of 
palpitation,  without  obvious  cause,  change  of  air, 
especially  to  the  seaside,  will  prove  very  advantageous. 
The  place  selected  should  be  one  that  is  sheltered  from 
high  winds,  with  level  walks,  and  at  no  great  altitude 
above  the  sea. 

For  palpitation  occurring  in  anaemic  subjects,  the 
preparations  of  iron  are  always  useful.  The  carbonate 
is  one  of  the  best,  and  quinine  or  other  bitter  tonics 
may  be  given  at  the  same  time.  When  the  patient  is 
nervous  as  well  as  anaemic,  and  irregularity  of  the 
heart's  action  accompanies  the  palpitation,  I  have  seen 
very  good  effects  from  small  doses  of  arsenious  acid  and 
digitalis,  taken  in  the  form  of  a  pill,  two  or  three  times 


TREATMENT  OF  PALPITATION.  387 

a  day,  for  five  or  six  weeks^  under  careful  medical 
observation.  When  the  disturbance  of  the  heart's 
action  occurs  in  persons  suffering  from  haemorrhoids 
the  condition  of  the  liver  will  require  attention,  and 
purgatives  are  generally  indicated.  The  question  of  a 
radical  cure  of  the  haemorrhoids  must  also  be  con- 
sidered. If  there  be  uterine  disorders,  as  evinced  by 
irregular  or  suppressed  menstruation_,  special  treatment 
will  be  requisite.  Hot  foot-baths  may  be  tried  to  re- 
store the  menstrual  discharge,  and  purgatives  are 
generally  indicated.  The  treatment  of  palpitation  in 
gouty  subjects  is  that  of  the  uric  acid  diathesis.  It 
may  be  briefly  summed  up  as  follows  :  careful  attention 
to  the  diet,  and  to  the  state  of  the  skin;  avoidance  of 
stimulants  and  excesses  of  all  kinds;  purgatives  and 
alkalies  with  tonics.  A  short  course  of  digitalis  will 
generally  be  useful  in  these  cases. 


CHAPTER    IIL 

SYNCOPE— SWOONING— FAINTNESS. 


Syncope,  Definition  and  Symptoms- — Incomplete  Attacks  or 
Faintness  —  Duration  of  Attacks  —  Causes,  the  Nervous 
System,  the  State  of  the  Heart,  the  Condition  of  the  Blood — 
Impressions  on  the  Nervous  System — Direct  Effects  on  the 
Heart — Mechanical  Causes,  Poisons — Syncope  Resulting  from 
loss  or  Deficiency  of  Blood — Mixed  Cases — Duration  of 
Attacks — Syncope  Distinguished  from  Epilepsy,  Apoplexy, 
Shock,  Concussion,  and  Poisoning — Prolonged  Syncope — 
Prognosis — Treatment — Restoration  of  Action  of  Heart, 
AND  Supply  of  Blood  to  the  Brain. 


Syncope  is  the  term  used  to  express  a" condition  due  to 
diminution  or  temporary  arrest  of  the  heart's  action_, 
and  characterized  by  more  or  less  complete  suspension 
of  consciousness  and  of  respiration^  and  usually 
attended  by  depression  of  the  temperature  of  the  body. 
It  may  be  briefly  described  as  inhibitory  paralysis  of 
the  heart.  The  condition  may  come  on  suddenly,  but 
is  more  often  preceded  by  a  feeling  of  nausea,  sinking" 
in  the  epigastrium,  giddiness,  weakness,  and  loss  of 
balancing  power,  some  disorder  of  vision  and  mental 
confusion,  noises  in  the  ears,  paleness  of  the  surface. 


SYMPTOMS  OF  SYNCOPE.  389 

and    chilliness.     When  the   syncope  is   complete^    the 
consciousness   is   entirely   suspended^  the  muscles    are 
relaxed^  the  face  is  deathly  pale  and  cold^  the  pulse  is 
imperceptible^  and  respiration  ceases  or  occurs  only  at 
long  intervals.       Convulsions  are  apt  to  occur   in  cases 
of  syncope  due  to  haemorrhage.     On    examining    the 
chest,  only  the  first  sound  can-  be  heard,  and  this  is 
much    weakened;    the   second    sound    may    be    quite 
inaudible.     This  condition  lasts  a  variable  time,  and  the 
first  signs  of  recovery  are  a  renewal  of  the  respiration 
and    movements  of  the  limbs.     After  a  few  deep  in- 
spirations,   the  pulse  becomes   perceptible,    the  colour 
slou'ly  returns  to  the  face  and  lips,  and  consciousness 
is  gradually  regained. 

In  less  marked  instances  the  loss  of  consciousness  is 
incomplete,  and  the  respiration  is  not  suspended,  but 
becomes  superficial  and  irregular.  The  pulse  can  be 
felt,  and  the  heart  sounds  are  audible,  but  much 
weakened.  The  patient  complains  of  sinking,  giddi- 
ness, and  nausea,  and  strives  to  adopt  the  recumbent 
position.  This  state  in  its  various  grades  is  described 
as  faintness,  and  is  of  very  common  occurrence. 

The  duration  of  syncope  varies ;  in  the  slighter 
degrees  the  sensations  may  last  for  considerable  periods. 


590  CAUSIJS  OF  SYNCOPIJ. 


alternately  diminishing  and  increasing  in  intensity  until 
they  completely  pass  off.  In  complete  syncope  the 
duration  seldom  extends  beyond  a  minute  or  two, 
unless  the  case  has  a  fatal  termination.  The  patient 
may,  however,  lie  for  hours  in  a  semi-conscious  con- 
dition, afraid  to  move  lest  the  worst  symptoms  should 
recur,  but  the  pulse  will  be  perceptible  and  the  heart 
sounds  more  or  less  audible.  These  serious  attacks, 
when  connected  with  organic  disease  of  the  heart,  may 
recur  again  and  again  until  a  fatal  issue  takes  place. 

The  causes  of  syncope  are  many  and  various  in  kind ; 
they  all  act  by  disturbing  and  interfering  with  the  action 
of  the  heart.  The  majority  affect  the  organ  through  the 
nervous  system ;  in  another  class  the  state  of  the  heart 
itself  is  the  cause  of  the  attacks.  Various  conditions 
of  the  blood  likewise  contribute  towards  the  causation 
of  syncope,  and  in  some  cases  several  causes  co-operate 
in  producing  an  attack. 

Many  causes  of  syncope  act  on  the  heart  through 
the  nervous  system,  and  of  these  violent  shocks  are 
the  most  frequent.  Under  this  heading  we  may  include 
the  effects  of  injuries  to  the  brain  or  other  parts,  and  of 
sudden  and  excruciating  pain,  of  offensive  or  fearful 
sights,  of  alarm,  or  of  exciting  or  depressing  intelli- 


CAUSES  OF  SFNCOFE.  391 

gence.  In  some  cases  the  same  effect  is  produced  upon 
the  heart  by  less  severe  impressions  on  the  nerv^ous 
system,  such,  for  example,  as  result  from  certain  op- 
pressive odours,  slight  irritation  of  the  stomach,  want 
of  food,  the  condition  of  other  internal  organs,  such  as 
the  uterus,  kidneys,  and  liver.  A  draught  of  cold  water, 
taken  when  the  body  is  hot  and  perspiring,  and  especi- 
ally if  likewise  exhausted  after  exercise,  has  been  known 
to  produce  fatal  syncope.  Persons  differ  greatly  as 
regards  their  liability  to  syncope.  In  nervous  women 
attacks  are  somewhat  common.  Many  of  the  heroines  of 
the  novels  written  in  the  last  century  were  remarkable  for 
their  proneness  to  faint  under  the  influence  of  surprise 
or  excitement.  Very  slight  causes  are  sometimes  suffi- 
cient to  induce  attacks  of  syncope.  Manv  years  ago, 
when  I  had  to  perform  a  large  number  of  vaccinations, 
many  adults,  who  came  to  be  revaccinated  used  to  faint 
under  the  slight  operation.  Several  medical  friends 
have  informed  me  that  they  have  met  with  similar 
experiences. 

The  state  of  the  heart  often  contributes  towards  the 
production  of  an  attack  of  syncope.  Thus  the  symptom 
is  very  common  in  many  organic  diseases,  and  especially 
in  aortic  stenosis  and  fatty  degeneration.    In  women  the 


392  CAVSJES  OF  SYNCOPE. 

heart's  action  is  often  seriously  interfered  with  by  tight 
lacing.  Other  causes  acting  directly  upon  the  heart  are  a 
high  temperature,  and  certain  powerful  drugs,  as  tobacco, 
digitalis,  hydrocyanic  acid,  and  chloroform.  To  these 
may  be  added  attacks  of  neuralgia  of  the  heart,  the 
metastasis  of  gouty  inflammation,  and  the  presence  of 
air  in  the  hearths  cavities. 

The  most  frequent  cause  of  syncope  is  loss  or 
deficiency  of  blood,  whether  due  to  haemorrhage  or  to  a 
slower  process  whereby  the  blood  is  robbed  of  some  of 
its  constituents.  The  effect  is  produced  chiefly  through 
the  brain,  and  is  often  suddenly  developed  in  cases  of 
loss  of  blood.  When  the  supply  of  blood  to  the  brain 
is  deficient,  the  consequences  are  seen  throughout  the 
body,  and  especially  in  the  muscular  system.  When  a 
person  is  in  the  erect  position  the  loss  of  blood  neces- 
sary to  produce  fainting  is  much  less  .than  in  the. 
recumbent  posture.  Hence  it  not  unfrequently  happens 
that  a  patient,  already  weak  from  deficiency  of  blood, 
faints  suddenly  on  attempting  to  rise  up  in  bed  ;  the 
lesson  to  be  learnt  from  such  experience  is,  of  course, 
obvious.  The  loss  requisite  to  produce  faintness  varies 
in  different  individuals  and  in  different  states  of  the 
system.    The  more  rapidly  the  blood  is  lost,  the  less  the 


DURATION  OF  SYNCOPE.  393 

quantity  necessary  to  produce  an  effect.  Profuse  dis- 
charges^ as  in  cholera  and  diarrhoea,  will  lead  to  the 
same  results,  and  the  sudden  removal  of  pressure, 
causing  a  rapid  removal  of  blood  from  one  part  of  the 
body  to  another,  will  also  cause  faintness.  This  may 
be  sometimes  seen  after  the  operation  of  tapping  the 
abdomen,  unless  proper  care  has  been  taken  to  keep  up 
the  pressure  by  means  of  a  bandage.  As  an  illustration 
of  a  parallel  character,  I  have  known  faintness  to  occur 
from  the  abrupt  discharge  of  a  large  quantity  of  wind 
from  the  stomach,  following  oppressive  distension  of 
that  orean.  A  marked  case  of  this  nature  has  recently 
been  published  by  Dr.  Goodridge  {Lancet,  April  21, 
1888). 

In  many  attacks  of  syncope  several  of  the  causes 
above  described  co-operate  in  the  production  of  the 
result.  Thus  in  anaemic  subjects,  the  effect  of  shock 
or  grief  is  aided  by  the  weakened  condition  of  the  heart 
and  the  deficiency  in  the  quantity  and  quality  of  the 
blood.  Also  in  cases  in  which  there  is  organic  cardiac 
disease,  an  attack  of  syncope  may  be  easily  induced  bv 
slight  causes,  and  particularly  by  gastric  distension. 

The  duration  of  attacks  of  syncope  has  been  already 
alluded  to;  it  may  extend  to  some  seconds  or  minutes. 


394  DIAGNOSIS  OF  SYNCOPE. 

in  rare  cases  the  condition^  with  various  modifications, 
continues  for  hours.  Incomplete  attacks,  i.e.,  those  in 
which  the  consciousness  is  not  entirely  lost,  are  the 
most  common ;  several  of  these  sometimes  follow  each 
other,  with  intervals  of  partial  recovery..  Except  in 
cases  of  organic  disease  of  the  he?irt  and  in  syncope  due 
to  haemorrhage,  complete  recovery  is  the  rule,  though 
for  some  time  after  the  attack  the  patient  may  feel 
anxious  and  giddy.  In  cases  in  which  the  symptoms 
are  prolonged  for  many  hours,  a  condition  of  apparent 
death  is  established  ;  consciousness  is  completely  lost, 
while  pulse  and  respiration  are  both  imperceptible. 
Very  careful  auscultation  will,  however,  detect  a  slight 
sound  over  the  heart. 

Attacks  of  syncope  require  to  be  distinguished  from 
other  conditions  attended  by  loss  of  consciousness, 
and  mainly  from  epilepsy,  apoplexy,  the  symptoms  of 
shock,  of  concussion  of  the  brain,  and  of  poisoning  by 
various  substances.  In  epilepsy,  the  loss  of  con- 
sciousness is  sudden  in  its  onset,  and  is  frequently 
accompanied  by  tonic  spasm,  succeeded  by  convulsive 
movements.  The  change  in  colour  which  the  face 
undergoes  from  pallor  to  lividity  is  a  distinguishing 
"  feature  of  epilepsy  as  compared  with  syncope.    Apoplexy 


DIAGNOSIS  OF  SYNCOPE.  395 

is  sometimes  ushered  in  with  an  attack  of  syncope,  the 
patient  becoming  faint  and  collapsed_,  with  pale  face^ 
cold  damp  skin_,  frequent,  feeble  and  irregular  pulse, 
nausea,  and  vomiting.  These  symptoms  are  soon 
followed  by  insensibility  and  coma.  Paralysis  also 
supervenes,  and  its  presence  is  sufficient  to  explain 
the  nature  of  the  case.  During  the  continuance  of 
the  coma  the  insensibility  is  profound,  the  face  is 
flushed  and  the.  skin  moist,  the  pulse  is  slow,  full,  and 
hard,  and  the  respiration  stertorous.  All  these  sym- 
ptoms are  sufficient  to  distinguish  the  attack  from  one 
of  syncope. 

The  symptoms  of  syncope  are  often  the  result  of 
shock,  but  in  cases  of  the  latter  kind  consciousness  is 
less  interfered  with,  and  may  be  almost  completely  pre- 
served. Tn  pure  shock  of  a  severe  character  the  patient 
is  at  first  stunned,  but  gradually  he  becomes  more  or 
less  aware  of  what  is  going  on,  and  is  able  to  answer 
questions,  and  this  state  of  partial  recovery  may  con- 
tinue indefinitely.  In  shock  with  excitement  the 
movements  of  the  patient  are  sufficient  to  distinguish 
the  symptoms  from  those  of  syncope.  In  the  collapse 
due  to  cerebral  concussion  the  insensibility  is  seldom 
quite  complete.     The  pupils  are  dilated,  and  in  other 


396  DIAGNOSIS  OF  SYNC  OFF. 

respects  the  symptoms  resemble  those  of  syncope. 
The  collapse  may  last  for  some  hours  when  the  pulse 
becomes  full,  the  skin  relaxed  and  hot_,  and  the  face 
flushed.     A  condition  of  drowsiness  then  supervenes. 

Loss  of  consciousness  results  from  the  operation  of 
several  poisons_,  especially  of  those  of  the  narcotic  class. 
With  regard  to  all  these,  however,  the  history  of  the 
symptoms  will  be  enough  to  distinguish  them  from 
those  of  syncope.  In  opium  poisoning,  moreover, 
the  face  is  suffused,  the  skin  warm,  the  breathing  slow 
and  deep,  and  the  pupils  are  contracted.  In  the  later 
stages  the  surface  becomes  cold,  and  the  face  is  pale 
and  cyanotic.  In  alcoholic  coma  the  pulse  is  slow  and 
laboured,  and  the  breathing  is  stertorous.  In  profound 
insensibility  due  to  chloroform  the  breathing  is  apt  to 
become  stertorous,  while  the  face  is  generally  suffused  ; 
the  pulse  may  remain  unaffected.  Pallor  of  the  counte- 
nance is  a  symptom  showing  that  an  excessive  quantity 
of  the  anaesthetic  has  been  given;  it  denotes  a  condition 
of  syncope  from  failure  of  the  heart's  action. 

In  cases  of  prolonged  syncope,  with  pulse  and  respira- 
tion imperceptible,  the  appearances  may  very  closely  re- 
semble those  of  death.  The  heart  should  be  very  care- 
fully examined,  and  the  temperature  should  be  taken  in 


TREATMENT  OF  SYNCOPE. 


397 


the  rectura.  The  setting-in  of  rigor  mortis  will,  of 
course,  determine  the  real  nature  of  the  symptoms,  but 
in  the  absence  of  this  conclusive  sign  of  death,  it  may 
be  difficult  to  express  a  positive  opinion. 

The  prognosis  in  cases  of  syncope  will,  of  course, 
mainly  depend  upon  the  cause  of  the  symptoms ;  it  is 
generally  favourable  unless  the  syncope  depends  upon 
organic  disease  or  profuse  hemorrhage.  The  facility 
and  rapidity  with  which  treatment  is  obtainable  may,  in 
severe  cases,  turn  the  scale  in  a  favourable  direction. 
In  the  case  of  severe  shocks  to  the  nervous  system, 
and  the  syncope  which  is  apt  to  follow  slight  exertion 
in  debilitated  subjects,  much  will  depend  upon  the  state 
of  the  patient  and  the  gravity  of  his  previous  condition. 
In  ordinary  cases  of  partial  syncope,  or  faintness,  due 
to  heat,  fear,  or  excitement,  or  to  impressions  on  the 
nerves  of  special  sense,  the  attacks  generally  pass  off  in 
a  few  minutes  if  proper  treatment  is  adopted  ;  but  thev 
are  very  liable  to  recur,  either  speedily  or  after  a  lon2:er 
interval.  In  cases  of  organic  disease  of  the  heart  suc- 
cessive attacks  of  syncope  are  often  noticed. 

Treatment.  In  dealing  with  a  case  of  syncope  we 
have  to  endeavour  to  restore  the  action  of  the  heart  and 
to  supply  as  much  blood  as  possible  to  the  brain.     The 


398  THEATIIJENT  OF  SYNCOPB. 

second  indication  can  be  fulfilled  while  remedies  to  act 
on  the  heart  are  being  sent  for.  The  patient  should  be 
placed  on  the  back  in  a  horizontal  position,  with  the 
head  as  low  as  or  even  lower  than  the  rest  of  the  body. 
This  simple  measure  often  serves  to  cut  short  an 
attack;  a  patient  subject  to  faintness  instinctively  seeks 
the  recumbent  position  when  he  feels  any  of  the  pre- 
monitory symptoms.  In  severe  cases,  as  after  excessive 
h3emorrhage_,  it  is  necessary  to  maintain  the  horizontal 
position  for  some  time^  and  to  be  very  careful  in  rising 
from  it.  At  the  same  time  that  this  position  is  adopted  all 
pressure  from  tight  articles  of  dress  should  be  carefully 
removed  from  the  neck,  chest,  and  abdomen;  pure, 
fresh  air  should  be  freely  admitted,  for  which  purpose 
the  windows  and  doors  should  be  thrown  open  and 
persons  should  be  prevented  from  crowding  round  the 
patient.  If  haemorrhage  be  the  cause  of  the  attack,  and 
is  still  going  on,  measures  must  be  adopted  to  arrest  it. 
All  the  above-mentioned  steps  should  be  taken  as 
rapidly  as  possible. 

Measures  should  also  be  employed  to  restore  the 
action  of  the  heart,  and  for  this  purpose  smelling  salts 
should  be  applied  to  the  nostrils,  and  diffusible  stimu- 
lants should    be    given.     A    little    spirit   of  ammonia. 


TR'EATMENT  OF  SYNCOPE.  399 

brandvj  or  eau  de  Cologne  are  those  which  are  generally 
at  hand.  Sprinkling  cold  water  on  the  face  is  also  use- 
fulj  inasmuch  as  it  incites  respiratory  efforts  by  which 
the  irritability  of  the  cardio-inhibitory  centre  is  much 
lessened.  A  still  greater  effect  in  this  direction  is 
produced  by  the  act  of  swallowing;  sipping  cold  water 
acts  as  a  powerful  cardiac  stimulant,,  and  in  most  cases 
of  syncope  recovery  is  not  long  delayed  after  the  patient 
is  able  to  swallow.  If,  however,  this  power  be  still  in 
abeyance,  a  stimulant  enema  should  be  injected  into  the 
rectum,  or  aether  may  be  administered  subcutaneously. 
If  these  measures  fail^  the  limbs  should  be  firmly  and 
energetically  rubbed  in  an  upward  direction,  and  warm 
applications  should  be  applied  to  the  body,  while 
ammonia  is  held  to  the  nostrils. 

When  the  syncope  is  the  result  of  an  overloaded 
stomach,  it  will  be  well  to  administer  an  emetic  of 
mustard  and  warm  water,  with  the  addition,  if  necessary, 
of  a  little  ipecacuanha.  I  have  seen  three  cases,  in 
elderly  persons,  of  syncope  from  an  overloaded  stomach  ; 
life  was  apparently  saved  by  the  prompt  administration 
of  an  emetic.  In  cases  in  which  the  attack  has  resulted 
from  a  draught  of  cold  water  taken  while  the  body  was 
heated,  the  patient,  if  able  to  swallow,  should  take  a  full 


4O0  TEJEATMjENT  OF  SYNCOPJE. 

dose  of  compound  spirit  of  aether  with  hot  brandy  and 
water,  and  in  cases  of  complete  unconsciousness^  these 
remedies  may  be  administered  by  means  of  the  stomach 
pump  or  in  an  enema.  At  the  same  time,  hot  fomenta- 
tions with  a  httle  turpentine,  or  a  mustard  plaister, 
should  be  applied  to  the  epigastrium.  As  a  matter  of 
course,  in  syncope  the  result  of  serious  haemorrhage  the 
question  of  transfusion  will  have  to  be  considered. 

In  all  cases,  after  the  attack  has  been  recovered  from, 
great  care  is  necessary  in  order  to  prevent  a  recurrence; 
the  erect  position  should  be  gradually  assumed  and 
exertion  abstained  from  until  sufficient  rest  and  nourish- 
ment have  been  taken  to  restore  the  nervous  energy 
reo-ulatinff  the  heart's  action.     In  cases  in  which  the 

o  o 

attack  has  been  due  to  distension  of  the  stomach,  the 
production  of  this  condition  must  be  prevented  by 
appropriate  diet  and  medicines.  Food  should  be  taken 
in  small  quantities,  and  articles  likely  to  engender  flatu- 
lence should  be  rigorously  forbidden. 


CHAPTER     IV. 

NEURASTHENIA  OF  THE  HEART. 


Weakness  of  the  Heart  in  Neurasthenia — Symptoms — Palpita- 
tion, Pain,  and  Sleeplessness- — Hypochondriasis — Special 
Cardiac  Symptoms — Periodicity  Sometimes  Noticed — Causes 
OF  Cardiac  Neurasthenia — Prognosis  and  Treatment. 


The  influence  of  the  nervous  system  upon  the  move- 
ments of  the  heart  accounts  for  the  frequency  with 
which  symptoms  of  cardiac  disorder  occur  among  the 
subjects  of  neurasthenia.  Weakness  of  the  heart's 
action  and  excessive  excitabihty  are  the  predominant 
features,  and  are  apt  to  give  rise  to  the  suspicion  of 
organic  disease.  In  typical  cases,  however,  there  are  no 
valvular  or  pericardial  lesions,  though  there  are  some- 
times grounds  for  suspecting  that  a  slight  degree  of  fattv 
degeneration  may  exist.  It  is  impossible  to  do  more  than 
speculate  as  to  the  nature  and  seat  of  the  nerv^ous 
disorder.  The  cardiac  ganglia,  the  sympathetic  system, 
the  medulla  oblongata,  and  the  pneumogastric  nerves 
may  all  be  implicated. 

The  special  symptoms  connected  with  the  heart  may 

26 


402       SYMPTOMS  OF  CARDIAC  NEURASTSENIA. 

be  the  first  to  appear,  but  it  more  commonly  happens 
that  they  set  in  at  a  later  stage.  They  are  more  frequent 
in  men  than  in  women.  Palpitation  and  pain  in  the 
precordial  region  are  first  complained  of,  and  appear  to 
aggravate  the  already  existing  weakness.  Attacks  of 
faintness  are  prone  to  occur,  and  obstinate  sleeplessness 
is  invariably  associated  with  the  cardiac  symptoms. 
Severe  attacks  of  hypochondriasis,  profound  melan- 
cholia, incapacity  for  mental  exertion,  sometimes  to 
such  an  extent  as  to  suggest  softening  of  the  brain, 
are  observed  in  some  cases.  The  hands  and  feet  are 
cold  and  moist,  the  face  and  lips  are  either  pale  or 
bluish  ;  numbness  and  formication  are  occasionally 
present  in  various  parts. 

The  special  cardiac  symptoms  are  a  small  and  infre- 
quent   pulse,    weakness    of   the    heart's    impulse,    and 
faintness  of  the  sounds.     In  some  of  these  cases  the 
number  of  the  pulsations  is  as  low  as  40  in  a  minute; 
'  after  a  meal  it  may  rise  to  50  or  perhaps  60  if  stimu- 
.lants  are  taken,  but  it  seldom  goes  beyond  the  latter 
number.     In   severe   cases   intermittency  of   the  pulse 
and    symptoms    resembling    those    of  angina    pectoris 
may  occur  from  time  to  time.     For  some  months  past 
I  have  had  under  my  care  a  young  man  aged  27,  with- 


SYMPTOMS  OF  CARDIAC  NEURASTHENIA.      40.-, 

out  any  sign  of  organic  disease_,  but  who  after  a  day's 
hunting  invariably  suffers  from  pain  in  the  cardiac 
region  with  an  intermittent  pulse.  I  advised  him  to 
relinquish  hunting,  and  he  has  since  had  no  return  of 
the  pain  in  the  chest_,  while  his  pulse  has  kept  quite 
normal.  A  curious  periodicity  is  sometimes  observed 
in  the  occurrence  of  the  syniptoms.  The  heart  may 
act  normally  for  some  hours,  the  patient  continuing  his 
occupation  and  being  either  quite  or  comparatively  free 
from  any  feeling  of  discomfort.  At  a  certain  time  of 
the  day_,  however,  perhaps  towards  evening,  the  sym- 
ptoms begin  to  show  themselves  ;  there  is  a  sensation 
of  pain  and  oppression  in  the  cardiac  region,  and  the 
heart  is  felt  to  be  acting  irregularly.  All  these 
symptoms  become  aggravated  if  work  is  persisted  in, 
but  they  subside  under  the  influence  of  rest.  They 
recur  from  time  to  time  under  similar  circumstances ;  it 
would  seem  as  if  the  nervous  mechanism  of  the  heart 
would  permit  of  a  certain  definite  amount  of  physical 
or  mental  exertion  and  would  work  smoothly  for  a 
limited  period,  but  no  longer.  Many  instances  of  this 
kind  have  come  under  my  notice.  Undue  excitability 
is  always  superadded  to  the  weakness  of  the  hearths 
action  ;  palpitation  and  pain  are  set  up  by  very  slight 


404      TSUATMIJNT  OF  CARDIAC  NEURASTHENIA. 

causes.  Few  of  these  patients  can  take  a  cup  of  coffee 
or  tea  without  suffering  for  it. 

It  is  very  necessary  in  these  cases  of  cardiac  neuras- 
thenia to  inquire  particularly  into  the  habits  of  the 
patient  in  order  to  discover  the  exciting  causes  of  the 
symptoms.  It  will  generally  be  found  that  some  form 
of  excess  is  the  source  of  the  mischief.  Alcohol  and 
tobacco^  abuse  of  sexual  intercourse,  prolonged  mental 
exertion,  an  insufficient  amount  of  sleep,  worry,  and 
anxiety  are  the  most  frequent  contributaries.  In  the 
absence  ot  treatment  the  symptoms  are  always  chronic, 
and  may  continue  for  some  years.  They  are  not 
dangerous  to  life,  but  should  the  patient  be  attacked  by 
any  severe  disease  his  chances  of  recovery  are  decidedly 
lessened.  Acute  bronchitis,  pneumonia,  and  any  form 
of  fever  may  easily  be  fatal  in  this  weakened  condition 
of  the  heart. 

The  treatment  consists  first  and  foremost  in  the 
avoidance  of  the  causes  (and  of  all  excesses  in  par- 
ticular), and,  secondly,  in  the  adoption  of  all  measures 
calculated  to  improve  the  general  health.  The  physician 
should  lay  down  definite  rules  for  the  guidance  of  the 
patient  in  all  such  matters  as  diet,  exercise,  occupation, 
rest,  etc.     The  food  must  be  of  a  decidedly  nutritious 


TREATMENT  OF  CARDIAC  NEURASTHENIA.     40.S 

character^  not  too  bulky  and  not  such  as  to  distend  the 
stomach  and  engender  flatulence.  Mutton  and  beef, 
game,  chicken_,  eggs,  and  white  fish  may  be  allowed  ; 
green  vegetables  are  suitable,  but  potatoes  and  farina- 
ceous food  in  general  should  be  taken  very  sparingly. 
Some  of  these  patients  are  unable  to  digest  bread ;  it 
causes  great  distension  of  the  stomach  and  much  dis- 
comfort. Toast  is  more  suitable ;  but  sometimes  it 
will  be  found  advisable  to  forbid  the  use  of  bread 
altogether,  and  let  the  patient  take  plain  biscuits 
instead.  Tea  and  coffee  must  be  interdicted  ;  cocoa  is 
well  adapted  for  these  cases.  The  nibs  should  be 
reduced  to  a  coarse  powder  and  boiled  gently  for  three 
hours;  the  liquor  is  then  strained,  and  when  cold  the 
fat  is  skimmed  off.  Thus  made,  the  decoction  will  keep 
good  for  two  or  three  days  ;  it  is  warmed  up  for  use  as 
required.  Great  moderation  as  regards  stimulants  is,  of 
course,  required.  If  the  patient  will  submit,  it  is  some- 
times well  to  try  the  eii^ects  of  abstinence ;  but  for  most 
cases  a  little  sound  claret  or  burgundy,  or  weak  whisky 
and  water  (not  more  than  two  ounces  of  the  spirit  in 
twenty-four  hours,  and  taken  only  with  meals),  will  do 
good  rather  than  harm.  Tobacco  must  be  strictly  for- 
bidden.    A   proper  amount  of  sleep    is    all-important, 


4o6      THEATMENT  OF  CARDIAC  NJEURASTRENIA. 

and  whenever  symptoms  of  fatigue  come  on  during  the 
day  the  patient  should  discontinue  his  occupation  and 
lie  down  for  an  hour  or  two.  Warm  baths  occasionally 
(to  be  always  followed  by  rest) ;  change  of  air  to  the  sea- 
side, or  other  suitable  locality^  and  the  administration 
of  suitable  tonics^  as  described  in  the  chapter  on  neuras- 
thenia, constitute  the  remainder  of  the  treatment. 


CHAPTER     V. 

ANGINA  PECTORIS— NEURALGIA  OF  THE  HEART, 


Angina  Pectoris,  Definition  of — Peculiarities  and  Symptoms  of 
THE  Attacks — The  Cardiac  Pain  and  Pulsations — Sounds 
of  the  Heart — Respiratory  Symptoms  and  Expression  of 
Countenance — Pains  in  the  Shoulder  and  Arm — Indications 
OF  Vaso-Motor  Disorder — Measures  Adopted  by  Patients 
TO  Relieve  Distress — Results  of  Attack  and  State  of 
Health  in  the  Intervals — Causes  of  a  Fatal  Termination — 
Causes  of  Angina,  Essential  and  Symptomatic — Influence 
OF  Tobacco  Smoking — Lesions  Found  after  Death  in  some 
Cases — Nature  of  the  Disorder — The  Nervous  Apparatus 
of  the  Heart — Three  Sources,  the  Cardiac  Ganglia,  the 
Pneumogastric,  and  the  Sympathetic^Vaso-Motor  Angina 
Pectoris  —  Diagnosis  —  Prognosis  —  Treatment,  Relief  of 
Attacks  and  During  Intervals — Subcutaneous  Injection  of 
Morphine  —  Inhalations  of  Nitrite  of  Amyl  —  Nitro- 
glycerine Internally — Stimulants — Hygienic  Measures — 
Arsenic — Treatment  of  Gouty  Subjects. 


Angina  pectoris  is  by  no  means  a  common  affection, 
but  inasmuch  as  cases  sometimes  occur  in  which  no 
organic  lesion  is  discoverable,  and  as  the  symptoms 
have  not  been  shown  to  depend  upon  any  specific  altera- 
tion, the  complaint  must  be  included  in  the  category  of 
functional  disorders  of  the  heart.  The  affection  is 
characterized  by  attacks  of  pain  which  begins  in  the 


4o8  SYMPTOMS  OF  ANGINA  PECTORIS. 

cardiac  region  and  extends  along  the  course  of  various 
nerves.  Alterations  in  the  movements  of  the  heart  and 
in  the  force  of  its  contractions  are  almost  always  asso- 
ciated with  the  pain. 

Attacks  of  angina  pectoris  are  wont  to  occur  in  the 
absence  of  any  obvious  cause.     Sometimes  they  come 
on  just  as  the  patient  is  going  to  sleep,  or  they  serve 
to  rouse  him  after  a  normal  sleep  of  some  hours.      In 
the  case  of  a  married  lady  whom  I  have  lately  attended^ 
the  attacks,  hitherto  three  in  number,  have  invariably 
come  on  just    as   the   patient  was  falling  asleep.     In 
other  cases  the  attacks  occur  irregularly,  and  are,  per- 
haps,  traceable    to   such    antecedents    as    exposure   to 
cold,  bodily  or  mental  exertion,  indigestion,  and  the  like. 
The  attacks  may  last  only  for  a  few  minutes,  or  they 
may  be  prolonged  for  hours.       In  rare  cases  the  sensa- 
tions   persist   with    remissions  only   for    several  days. 
With  regard  to  their  recurrence  there  may  be  months 
or  even  years  of  freedom,  while  in  other  cases  attacks 
come    on    daily,  or  even   several    times  a  day.     As  a 
general  rule,  the   attacks    become   more    frequent  and 
more  severe  as  time  goes  on.       They  generally  occur 
without  any  premonitory  symptoms,  but  in  some  cases 
they  are  preceded  by  vertigo,  noises  in  the  ears,  ocular 


SYMPTOMS   OF  ANGINA  PECTORIS.  409 

spectra,  uausea_,  difficulty  of  swallowing,  chilliness,  and 
various  other  uncomfortable  sensations. 

The  strongest  possible  epithets  are  used  by  the 
patients  to  describe  the  character  of  the  pain  which  is 
felt  beneath  the  lower  half  of  the  sternum  and  in  the 
region  of  the  left  nipple.  It  is  said  to  be  of  a  pricking, 
burning;;,  borins;  character,  as  if  a  hot  iron  were  beinor 
driven  into  the  chest,  or  as  if  the  heart  were  being  torn 
t)ut  of  it;  in  other  cases  the  sensation  is  one  of 
pressure  and  constriction.  A  sensation  of  impending 
dissolution  is  always  superadded.  The  objective 
symptoms  are  also  likewise  prominent ;  the  heart  beats 
tumultuously  and  with  greatly-increased  frequency  and 
strength.  The  first  sound  is  accompanied  by  a  metallic 
ringing;  the  pulse  at  the  wrist  is  hard,  but  inter- 
mittent. An  opposite  condition  of  the  hearths  action, 
viz.,  diminished  frequency  and  strength,  with  a  weak 
pulse,  is  less  frequently  noticed. 

Respiratory  troubles  are  always  associated  with  the 
symptoms  just  described.  There  is  an  intense  feeling 
of  want  of  air  in  the  chest,  but  the  inspirations  are 
irregular,  superficial,  jerking,  and  sighing,  and  suffoca- 
tion appears  imminent.  These  "  symptoms  are  due 
to   reflex  action,   resulting  from   the   cardiac   pain,   for 


41  o  SYMPTOMS  OF  ANGINA  FJECTOmS. 

there  is  no  disease  of  the  respiratory  organs,  and  by  a 
strong  effort  of  the  will  the  patients  can  take  deep  and 
regular  inspirations.  The  expression  of  the  countenance 
indicates  the  patient's  sufferings  in  an  unmistakable 
manner;  the  features  are  distorted  and  pale,  and  the 
face  is  covered  with  cold  perspiration. 

Neuralgic  pains,  due  presumably  to  irradiation,  are 
almost  always  felt  along  the  course  of  various  nerves. 
The  region  of  the  shoulder  and  the  left  arm  are  the 
parts  most  commonly  affected,  but  sometimes  the 
suffering  is  coiifined  to  the  back  and  inner  side  of  the 
arm  which  is  supplied  by  the  internal  cutaneous  nerve. 
In  other  cases  the  pain  reaches  to  the  forearm,  follow- 
ing the  course  and  distribution  of  the  ulnar  nerve.  The 
patients  generally  complain  of  a  sense  of  numbness  and 
stiffness  in  the  arm,  and  sometimes  of  formication,  and 
these  feelings  may  persist  long  after  the  pain  has 
abated.  The  pain  in  the  arm  is  sometimes  a  pre- 
monitory symptom,  and  not  unfrequently  the  part 
is  the  seat  of  severe  cutaneous  hyperaesthesia.  It 
rarely  happens  that  the  pain  affects  both  arms  or  the 
right  arm  alone,  but  it  often  extends  to  the  left  side  of 
the  neck.  Pain  in  the  face  is  rare,  but  uncomfortable 
sensations  are  often  felt  in  the  upper  part  of  the  thorax, 


SYMPTOMS  OF  ANGII^A  PECTORIS.  4rr 

and  the  nipple  is  sometimes  very  painful  and  tender  on 
pressure.  In  exceptional  cases  pain  radiates  to  the 
back,  and  likewise  over  the  abdomen  and  dov^nwards  to 
the  leo-s.  I  have  v^itnessed  one  attack  in  an  old  man 
in  which  the  pain  extended  behind  the  left  shoulder- 
blade  down  the  left  arm,  and  was  also  felt  in  the  left 
iliac  fossa.  Indications  of  spasm  are  witnessed  in 
many  cases  ;  thuS;,  swallowing  is  often  difficult,  while 
vomiting,  difficulty  of  speaking,  hiccough,  and  epilepti- 
form convulsions  are  not  unfrequent. 

Indications  of  vaso-motor  disorder  are  always  pre- 
sent. The  extremities  are  pale  and  marked  with  livid 
discolorations,  while  their  temperature  is  lower  than 
normal.  These  phenomena  are  attributable  to  spasm  of 
the  minute  cutaneous  vessels,  and  are  occasionally  so 
decided  as  to  give  rise  to  the  supposition  that  the 
nervous  disorder  is  not  of  a  secondary  character,  but 
that  the  vaso-motor  changes  are  the  primary  factors, 
and  that  they  precede  and  cause  the  attacks  of  cardiac 
pain.  Cases  such  as  these  have  been  described  as  vaso- 
motor angina  pectoris,  and  are  explained  by  supposing 
that  the  spasm  in  the  cutaneous  arteries  raises  the  blood- 
pressure  in  the  aorta,  and  causes  the  alterations  in  the 
heart's  action. 


412  SYMPTOMS  OF  ANGINA  PECTORIS. 

When  an  attack  of  angina  is  impending,  most 
patients  know  by  experience  that  they  will  be  relieved 
by  fresh  air,  and  they  consequently  hurry  to  a  window 
or  out  of  the  house.  As  a  general  rule  they  find  that 
the  erect  posture  serves  to  mitigate  their  sufferings ; 
besides  this  they  often  seize  the  nearest  object  and 
press  it  against  the  chest,  or  they  clasp  the  left  side  of 
the  thorax  with  their  hands.  When  the  attack  is  at  its 
height,  the  slightest  noise  or  disturbance  worries  the 
patient,  whereas  he  is  relieved  by  quiet  and  a  darkened 
room.  The  urine  passed  after  an  attack  is  pale,  watery, 
and  copious  in  quantity.  If  a  paroxysm  lasts  for  some 
time  the  patient  may  become  quite  prostrate,  or  even 
completely  unconscious;  the  respiration  almost  ceases, 
the  pulse  is  imperceptible  and  the  heart  sounds  scarcely 
audible,  so  that  the  patient  is  reduced  to  a  condition  of 
apparent  death. 

Sometimes  the  attack  passes  off  suddenly ;  in  other 
cases  it  subsides  after  eructation,  vomiting,  or  diarrhoea  ; 
copious  expectoration  has  been  observed  in  a  few 
instances. 

In  the  intervals  between  the  attacks,  the  majority  of 
the  patients  feel  comparatively  or  even  quite  well,  but 
they  are  always  disturbed  by  fear  that  recurrences  may 


CAUSES  OF  ANGINA  PECTORIS.  413. 

take  place.  If  organic  lesions  be  present,  their  symptoms 
will  be  more  or  less  troublesome.  The  first  attack  of 
angina  is  sometimes  fatal_,  as  in  the  case  of  the  late  Dr. 
Arnold,  of  Rugby ;  on  the  other  hand,  attacks  may 
continue  to  recur  during  many  years  and  without  much 
apparent  injury  to  the  general  health.  In  fatal  cases 
death  generally  occurs  from  paralysis  of  the  heart ; 
rupture  of  the  organ  and  cerebral  haemorrhage  have  been 
occasionally  observed.  Some  patients  gradually  fall  into 
a  low  cachectic  state,  and  eventually  die.  Sudden  death 
under  the  influence  of  strong  emotion  has  been  recorded 
in  a  few  subjects  of  angina  pectoris. 

Nothing  definite  can  be  stated  with  regard  to  the 
causes  of  angina  pectoris.  The  complaint  is  much 
more  common  in  males  than  in  females,  and  the 
majority  of  the  sufferers  are  over  fifty  years  of  age. 
Hereditary  predisposition  is  sometimes  traceable,  as  in 
Dr.  Arnold's  case ;  in  other  instances  there  is  a  family 
history  of  other  nervous  disorders.  Rheumatism,  gout, 
and  excesses  in  alcohol  and  tobacco  play  a  more  or  less 
active  part  in  the  causation  of  angina  pectoris.  Certain 
it  is  that  in  some  cases  the  attacks  cease  when  tobacco- 
smoking  is  given  up,  and  recur  on  resumption  of  the 
habit.     The  complaint  is  said  to  be  more  common  in 


414  CAUSJES  OF  ANaiNA  PJECTORIS. 

well-to-do  persons^  leading  sedentary  lives^  and  dis- 
posed to  obesity.  It  is  much  more  frequent  in  cold 
than  in  warm  climates. 

In  endeavouring  to  trace  the  disorder  to  its  cause,  it 
is  well  to  divide  the  cases  into  two  groups,  the  first  of 
which  embraces  those  in  which  no  organic  lesion  is 
discoverable,  and  the  second  those  in  which  certain 
organs  are  manifestly  diseased.  To  the  first  class  the 
term  "  essential "  has  been  applied ;  it  includes  not 
more  than  five  per  cent,  of  the  total  number  of  cases. 
Among  the  most  prominent  causes  which  have  been 
assigned  for  cases  of  this  kind  are  exposure  to  cold, 
mental  excitement,  and  excessive  indulgence  in  alcohol 
and  tobacco.  With  regard  to  -cold,  it  may  be  supposed 
to  contribute  at  least  towards  the  causation  of  vaso- 
motor angina  pectoris,  examples  of  which  are  usually 
seen  in  cold  and  damp  climates  when  the  weather  is 
very  severe. 

In  cases  of  symptomatic  angina,  the  most  common 
changes  found  after  death  are  those  which  affect  the 
organs  of  the  circulation,  such  as  atheromatous  degenera- 
tion in  the  aorta  and  coronary  arteries,  aneurism  of  the 
aorta,  and  insufficiency  of  the  aortic  valves.  Angina  is 
a  less   fiequent  accompaniment   of  mitral  disease  and 


PATHOGJENY  OF  ANGINA  PECTORIS.  41  f; 

fatty  degeneration  and  of  pericardial  adhesions.  Gout 
and  rheumatism  seem  to  play  an  important  part  in  the 
production  of  the  disorder.  As  of  purely  reflex  origin, 
symptoms  of  angina  have  been  observed  in  diseases  of 
the  kidney,  liver_,  and  uterus,  and  in  a  case  of  stone  in 
the  bladder. 

Many  attempts  have  been'  made  to  explain  the 
symptoms  and  nature  of  angina  pectoris.  With  regard 
to  the  chano;es  found  in  the  heart  and  in  the  blood- 
vessels^  it  cannot  be  regarded  as  certain  that  these  are 
the  cause  of  the  attacks,  for  hundreds  of  patients  suffering 
from  diseases  of  the  heart  never  exhibit  any  symptoms  of 
angina  pectoris.  On  the  other  hand,  in  some  fatal 
cases  of  the  disorder  no  morbid  changes  whatever  have 
been  discovered  in  the  ors:ans  of  circulation. 

If  we  regard  the  symptoms  as  the  result  of  disordered 
innervation^,  it  is  well  to  inquire  as  to  the  changes  that 
have  been  discovered  in  the  nervous  apparatus  of  the 
heart.  There  are,  unfortunately,  but  few  accounts  giving 
trustworthy  details.  Pressure  on  the  cardiac  branches 
of  the  pneumogastric  by  enlarged  bronchial  glands,  and 
increased  vascularity  and  hyperplasia  of  the  connective 
tissue  of  the  cardiac  plexus  have  been  noticed  in  a  few 
cases.     The  most  important  changes  are  those  which 


4ib  FATHOGENY  OF  ANGINA  PECTORIS. 

have  been  discovered  in  the  cardiac  gangUa  themselves. 
These  organs  in  one  case^  in  which  during  Ufe  there 
were  symptoms  of  angina  pectoris,  were  found  to  be  in 
a  state  of  hyperaemia  with  interstitial  inflammation  and 
increased  growth  of  connective  tissue;  some  of  the 
gangHa  were  destroyed,  and  the  interstitial  tissue  was 
infiltrated  with  calcareous  matter. 

The  physiological  explanation  of  paroxysms  of  angina 
is  extremely  difficult  on  account  of  the  complex  manner 
in  which  the  heart  is  supplied  with  nerves.  It  has  been 
pointed  out  in  the  introductory  chapter  (see  page  0^62) 
that  this  supply  is  derived  from  three  sources  :  in  the 
first  place  there  are  the  ganglia  in  the  substance  of  the 
heart  itself;  and  these  are  independent  centres  of  nerve 
force.  In  the  second  place  there  are  the  branches  of 
the  pneumogastric,  which  regulate  the  action  of  the 
heart ;  and,  lastly,  there  are  the  branches  of  the  sympa- 
thetic, which,  with  those  just  mentioned,  .form  the 
highly  complicated  cardiac  plexus.  It  cannot  be 
wondered  at  that  many  symptoms  of  disorder  of  this 
plexus  should  fail  to  correspond  with  those  of  experi- 
ments made  upon  the  vagus  and  upon  the  sympathetic. 

It  has  been  proved  that  the  cardiac  ganglia  can  be 
irritated  or  paralyzed  by  solutions  of  various  substances 


PATHOGENY  OF  ANGINA  PECTORIS.  417 

brought  into  contact  with  the  endocardium  ;  and  it  may 
be  inferred  that  a  similar  result  might  follow  alterations 
in  the  quantity  or  quality  of  the  blood.  If  the  ganglia 
are  irritated  the  heart's  action  is  increased  and  accele- 
rated ;  if  they  are  paralyzed  an  opposite  condition  of 
things  is  set  up,  and  may  go  as  far  as  to  amount  to 
suspension  of  the  heart's  action.  Such  a  condition 
might,  therefore,  result  from  narrowing  or  closure  of  the 
coronary  arteries  which  supply  blood  to  the  ganglia.  It 
can  easily  be  ima2:ined  that  in  atheromatous  degrenera- 
tion  of  the  aorta  and  in  disease  of  the  aortic  valves  the 
blood  supply  of  these  ganglia  might  be  much  diminished, 
or  even  temporarily  cut  off. 

The  pneumogastric  nerve  may  be  affected  either 
directly  or  by  reflex  action.  Stimulation  of  the  cardiac 
branches  may  be  produced  by  irritation  of  the  abdominal 
organs,  as  in  the  experiment  of  Goltz,  of  tapping  the 
intestines.  In  cases  of  angina,  provoked  by  indiges- 
tion, the  irritation  is  propagated  by  the  sympathetic 
nerves  through  the  cervical  spinal  cord  to  the  pneumo- 
gastric. The  result  is  diminished  frequency  of  the 
heart's  action,  amounting,  perhaps,  to  temporary  sus- 
pension, with  impediments  to  intonation  and  to  swallow- 
ing.    The  pain,   which   is   likewise  present,  is  due  to 

37 


4i8  PATHOGENY  OF  ANGINA  PECTORIS. 

irritation  of  the   sensory  fibres   which  are  .contained  in 
both  the  vagus  and  the  sympathetic.     The  extension  of 
the  pain  to  the  shoulders  and  arms  is  due  to  the  connec- 
tions which  these  nerves  form  with  the  brachial  plexus. 
The  last  set  of  nerves  to  be  considered  in  connection 
with  this  affection  of  the  heart  are  those   derived  from 
the    sympathetic    system.     Irritation   of  these    nerves 
accelerates  the  heart's  action.     In  vaso-motor  angina 
pectoris   increased  force  of  the  cardiac  contractions  is 
requisite   in    order    to   overcome  the    obstacles    in    the 
peripheral  vessels.     The  forced  contractions  give  rise  to 
pain  analogous  to  that  felt  in  the  calves  of  the  legs_,  and 
in  some  disordered  states  of  the  uterus.     The  paroxysm 
of  angina  comes  to  an  end  as  soon  as  the  spasm  of  the 
cutaneous  vessels  has  been  relieved  by  warmth  or  other- 
wise, and  an  impediment  to  the  free  circulation  of  blood 
no  longer  exists.     It  has  been  supposed  that  congenital 
weakness  of  the  cardiac  nerve-centres  exists   in  some 
cases,  and   that  in   others  a  weakened  condition   may 
result  from  immoderate   muscular  or   mental    exercise. 
Attacks  of  angina  have  been  observed  for  the  first  time 
in   persons    who,    after    recovery    from    serious  illness, 
have  overtaxed  their  strength^  and  in  others  who  have 
been  reduced  by  mental  strain  or  want  of  sleep. 


TREATMENT  OF  ANGINA  PECTORIS.  419 

The  diagnosis  of  angina  pectoris  is  for  the  most  part 
easily  inade^  the  distinguishing  feature  being  the  severe 
paroxysmal  pain  in  the  cardiac  region.  The  attacks 
can  scarcely  be  mistaken  for  those  of  ordinary  palpita- 
tion or  of  asthma_,  or  hysteria.  It  is_,  of  course,  im- 
portant to  determine  whether  there  be  any  organic 
affection  of  the  heart  or  vessels.  These  should  always 
be  carefully  examined,  and  if  the  physician  sees  the 
patient  during  an  attack,  he  can  scarcely  make  a  mis- 
take as  to  the  nature  of  the  symptoms. 

The  prognosis  is  always  more  or  less  unfavourable. 
If  an  organic  lesion  be  present^  its  nature  will  determine 
the  opinion  of  the  physician^  but  even  in  the  absence 
of  any  such  change  angina  is  always  a  serious  com- 
plaint, and  may  either  cause  sudden  death  or  may  wear 
out  the  patient  by  the  frequency  and  severity  of  the 
attacks..  The  vaso-motor  form  and  those  in  which  the 
affection  is  connected  with  some  abdominal  disorder,  or 
with  excess  in  alcohol  or  tobacco,  admit  of  a  somewhat 
more  favourable  prognosis. 

The  treatment  of  angina  pectoris  resolves  itself  into  a 
consideration  of  the  measures  to  be  taken  to  r^^lieve  an 
attack,  and  of  those  best  adapted  to  prevent  recurrences. 
When  a  paroxysm  of  angina  is  threatening,  the  patient 


420  TBEATMEJs^T  OF  ANGINA  PECTORIS. 

should  be  placed  in  a  qulet^airy  room,  with  the  windows 
open,  but  somewhat  darkened ;  and  the  clothes  about 
the  neck  and  chest  should  be  loosened.  Most  patients 
find  that  a  sitting  posture  affords  most  relief.  Sucking 
ice  tends  to  mitigate  the  distress,  and  cold  applications 
to  the  prsecordia  are  generally  grateful  to  the  patient. 

As  a  general  rule  in  all  cases  of  functional  disorder  of 
the  heart,  attended  bv  palpitation  and  irregular  action^ 
it  is  of  great  importance  that  the  physician  should  gain 
the  confidence  of  the  patient  by  assuring  him  that  he 
has  no  organic  disease,  and  that  the  attack  will  yield  to 
treatment. 

With  regard  to  medicines,  the  subcutaneous  injection 
of  gr.  ^  of  morphine  will  sometimes  speedily  relieve  all 
the  symptoms,  but  the  practice  is  not  without  risk  in  cases 
of  fatty  degeneration  of  the  heart.  The  same  remark 
applies  to  the  use  of  chloroform  and  aether,  the  former 
of  which  has  been  known  to  cause  epileptiform  attacks, 
followed  by  severe  collapse.  Inhalations  of  the  nitrite 
of  amyl  are  often  very  efficacious,  and  they  are  especially 
suitable  for  cases  in  which  there  is  coldness  and  pallor 
of  the  skin  or  livid  discoloration,  symptoms  due  to 
spasm  of  the  cutaneous  vessels.  The  remedy  may  be 
used  by  dropping  niv  on  a  handkerchief,   and  allowing 


TRI:ATMENT  of  angina  pectoris.  42 t 

the  patient  to  inhale  it  until  the  face  becomes  red  and 
there  is  a  feeling  of  pulsation  in  the  head.  It  is  well  to 
let  the  patient  have  the  nitrite  enclosed  in  capsules, 
each  containing  three  minims  and  encased  in  cotton 
wool  and  silk.  When  used  the  glass  capsule  is  broken, 
the  liquid  soaks  the  cotton  wool  and  silk  cover,  and 
<can  be  conveniently  inhaled. 

Dr.  Murrell  has  recently  recommended  nitro-glycerine 
for  the  relief  of,  or  to  ward  off  attacks  of  angina  pectoris. 
A  I  per  cent,  solution  in  rectified  spirit  is  prepared,  and 
•of  this  3  to  5  minims  are  given  when  an  attack  is  im- 
pending. In  some  cases  it  gives  complete  relief,  and  is 
thus  a  great  boon  to  the  sufferers  who  acquire  perfect 
•confidence  in  being  able  to  control  the  attacks.  The 
remedy  may  also  be  conveniently  administered,  com- 
bined with  chocolate  in  the  form  of  lozenges,  each  con- 
taining Y^  of  a  grain.  Stimulants  must  be  given  if 
during  an  attack  there  be  evidences  of  cardiac  exhaus- 
tion, such  as  a  much  weakened  impulse,  with  scarcely 
audible  heart-sounds  and  a  very  feeble  pulse.  Under 
such  circumstances  brandy  should  be  given  if  the 
patient  be  able  to  swallow,  and  if  not,  some  aether  should 
be  subcutaneously  injected.  At  the  same  time  the  feet 
should  be   placed  in  hot  water,  and  a  mustard  plaster 


422  TEUATMJSNT  OF  ANGINA  FECTORIS. 

applied  to  the  chest.  In  vaso-motor  angina  pectoris 
the  application  of  heat  to  the  extremities  is  always 
useful. 

In  order  to  prevent  recurrences  of  the  attack  the 
patient's  habits  and  mode  of  life  must  be  carefully 
regulated.  All  excess  in  eating  and  drinking,  and  in 
the  use  of  tobacco  is  to  be  strictly  prohibited ;  it  is, 
indeed,  well  to  forbid  tobacco  altogether.  •  The  bowels 
should  be  kept  regularly  open ;  the  patient  should  take  a 
fair  amount  of  exercise  in  the  open  air,  but  always  short 
of  fatigue ;  he  should  have  a  tepid  sponge  bath  daily, 
and  scrupulously  avoid  exposure  to  cold  and  mental 
excitement.  Change  of  air  often  does  good  to  these 
patients;  the  seaside  suits  some;  others  are  benefited  by 
a  sojourn  in  elevated  districts  if  sheltered  from  high 
winds.  If  organic  disorders  be  present,  these,  of 
course,  require  appropriate  treatment;  anaemia  must 
be  combated  by  iron  and  quinine,  and  nutritious 
diet ;  nervous  excitement  by  bromide  of  potassium  and 
various  tonics.  If  there  be  valvular,  or  other  disease  of 
the  heart,  with  irregular  action,  digitalis  is  likely  to  be 
suitable.  When  there  are  evidences  of  fatty  degenera- 
tion of  the  heart,  a  course  of  arsenic,  with  strychnine, 
may  be  tried.     Arsenic  is  also  useful  in  cases  in  which 


TREAT3IENT  OF  ANGINA  PECTORIS.  423 


the  patients  are  much  depressed.  A  case  has  been 
recorded  in  which  the  attacks  were  aggravated  by  the 
condition  induced  by  a  hot  summer  -,  other  remedies  had 
been  tried  without  avail^  when  an  immediate  improve- 
ment followed  the  administration  of  Fowler's  solution 
in  doses  of  two-and-a-half  minims  three  times  a  dav. 
For  gouty  cases  the  treatment  of  the  uric  acid  diathesis 
should  be  rigorously  carried  out.  A  course  of  bicarbo- 
nate of  sodium,  combined  with  ammonia  and  some 
bitter  tonic,  is  certain  to  be  useful.  The  diet  and  con- 
dition of  the  stomach  will  require  careful  attention.   . 


SECTION    III. 

FUNCTIONAL   DISORDERS   OF   THE  RE- 
SPIRATORY ORGANS. 


INTRODUCTORY    CHAPTER. 


Functional  Disorders  of  Respiration — Nerves  of  Sensation  or 
Motion  Implicated — Disorders  of  the  Voice — Hoarseness — 
Aphonia  and  its  Causes — Laryngeal  Growths,  Catarrhal 
Swelling,  Paralysis  of  the  Laryngeal  Muscles,  Hysteria, 
An/Emia  —  Dysphonia  Clericorum  —  Insufficient  Stream  of 
Air — Treatment  of  Hoarseness  and  Aphonia — Inhalations 
— Tonics — Mineral  Waters  —  Faradism  —  Anesthesia  and 
Hyperesthesia  of  the  Respiratory  Nerves — Neuralgia  of 
the  Larynx  —  Treatment  —  Nervous  Cough — Symptoms  — 
Causes — Connection  between  Cough  and  Affections  of  the 
Ear — Treatment. 


Functional  disorders  of  the  respiratory  organs  are 
characterized  by  symptoms  referable  in  the  main  either 
to  the  nerves  of  sensation  or  those  of  motion  or  to 
both  at  the  same  time.  Moreover,  in  the  Iarynx_,  dis- 
orders are  apt  to  occur  involving  alterations  in  the 
voice^  independently  of  inflammation   or  other  organic 


426  CAUSUS  OF  APHONIA. 


change;  and   It   will  be  convenient  to   consider   these 
first. 

The  condition  of  the  voice  known  as  hoarseness  is 
most  often  caused  by  mucus  upon  the  vocal  cords ;  it 
may  be  also  due  to  swelling,  roughness^  and  defective 
tension  of  these  structures.  '  If  while  speaking  the 
cords  suddenly  come  together^  the  speech  is  broken, 
owing  to  the  formation  of  nodal  points  (Landois). 
Hoarseness  sometimes  precedes  complete  loss  of  voice 
or  aphonia  ;  but  the  latter  may  occur  alone  and  come 
on  either  gradually  or  suddenly. 

Aphonia  is  liable  to  occur  when  anything  prevents  or 
impedes  the  free  vibrations  of  the  vocal  cords.  A 
tumour  on  one  or  both  of  these  structures  is  a  cause  of 
this  character_,  and  the  same  effect  may  be  produced  by 
catarrhal  swelling  of  the  cords,  and  likewise  by  a  similar 
condition  of  the  false  vocal  cords  and  adjacent  parts. 
The  swollen  mucous  membrane  impedes  the  vibrations,, 
by  encroaching  on  the  space  in  which  these  take  place. 

Another  cause  of  aphonia  is  paralysis  or  weakness- 
of  the  laryngeal  muscles.  Examples  of  such  paralysis, 
of  a  functional  character,  are  seen  in  cases  of  hysteria. 
In  such  patients  there  is  no  considerable  alteration  in. 
the  mucous  membrane  which  is  healthy  and  of  normal 


CA  USES  OF  A  P  RON  I  A .  427 

colour,  or  at  most  Ijut  slightly  congested.  The 
hyperaemia,  which  is  an  occasional  accessory,  is  due 
perhaps  to  the  same  causes  as  those  which  produce  the 
aphonia,  or  is  of  a  secondary  character.  In  not  a  few 
of  these  cases  the  vocal  cords  approximate  as  in 
health. 

In  another  class  of  cases  bclono-incr  to  this  cate2:orv, 
the  mucous  membrane  of  the  larynx  is  pale  and  anaemic, 
a  condition  which  coincides  with  the  aspect  of  the- 
patients.  The  aphonia  is  due  to  imperfect  approxi- 
mation and  insufficient  tension  of  the  vocal  cords. 
There  are  yet  other  patients  who  present  this  symptom, 
but  are  neither  hysterical  nor  anaemic,  and  the  aphonia 
must  be  regarded  as  due  to  some  perverted  distribution 
of  nerve-force.  Such  purely  functional  aphonia  appears 
generally  in  girls  and  young  women  under  thirty.  In 
loss  of  voice  occurring  in  the  patients  just  referred  to, 
the  symptoms  may  come  on  suddenly,  as  a  result  of 
sudden  and  strong  mental  emotion,  caused,  for  example, 
by  joy,  anger,  or  fright.  In  other  cases  its  accession  is 
gradual,  depending  upon  general  debility,  as  after  long- 
continued  and  exhausting  diseases.  The  aphonia  in 
another  class  of  cases  is  due  to  debility  of  the  laryngeal 
muscles,  as  when  these   have   been  overstrained  by  ex- 


428  CAUSES  OF  APHONIA. 

cessive  or  protracted  use  in  speaking  or  singing.  The 
voice  may  be  reduced  to  a  whisper^  or  perfectly  in- 
audible. In  so-called  dysphonia  clericorum,  chronic 
catarrh  and  swelling  of  the  mucous  membrane  of  the 
larynx  are  combined  with  loss  or  impairment  of  muscular 
power,  but  the  latter  may  exist  alone.  Under  such 
circumstances/  the  patient  can  read  or  talk  for  half  an 
hour  or  more^  but  then  the  voice  becomes  feeble_,  and 
less  and  less  audible.  There  is  a  sensation  of  fatigue 
and' pain  in  the  larynx^  but  there  is  no  decided  change 
visible  on  examination_,  certainly  none  sufficient  to 
account  for  the  loss  of  voice. 

Another  cause  of  aphonia  is  an  insufficient  stream 
of  air;  "  the  vocal  pipe  feebly  blown  through  refuses  to 
speak."  This  condition  is  seen  in  cases  of  faintness 
and  collapse  from  various  causes,  in  emphysema,  and  in 
attacks  of  asthma.  Intercostal  neuralgia  is  another 
cause  of  this  character;  the  patient  fears  to  use  liis 
chest  in  consequence  of  the  pain ;  and  atrophy  of  these 
muscles  leads  to  a  similar  result.  It  must  not  be  for- 
gotten that  acute  enlargement  of  the  tonsils  may  cause 
almost  complete  aphonia,  owing  to  the  insufficient 
amount  of  air  which  is  allowed  to  pass  upwards. 

The  treatment   of  hoarseness  and  aphonia  depends 


TREATMENT  OF  APHONIA.  429 

upon  the  cause  of  the  affection.  When  catarrh  Is 
present,  cold  compresses  to  the  throat,  local  astringents, 
and  the  inhalation  of  medicated  vapours  are  likely  to 
prove  serviceable.  One  of  the  best  local  astringents  is 
the  chloride  of  zinc  (gr.  xxx  to  $]  glycerine)  applied  by 
means  of  a  brush  daily  or  every  alternate  day.  Carbolic 
acid  pigment  of  the  same  strength  is  useful  when  the 
mucous  membrane  is  dry  and  shining  (Mackenzie). 
The  vapour  of  Scotch  pine  (Pinus  sylvestris)  forms  a 
mild  stimulant  inhalation  for  slight  laryngeal  catarrh, 
and  the  vapours  of  crcasote^  juniper_,  and  benzoin  may 
be  employed  for  the  same  purpose.  These  inhalations 
sholild  be  used  twice  or  three  times  daily  for  about  ten 
minutes  at  a  temperature  of  140°.  Another  useful 
remedy  is  powdered  gum  eucalyptus  gr.  J  with  an 
equal  quantity  of  powdered  starchy  applied  by 
means  of  an  insufflator^  and  when  the  pharynx  is 
affected,  the  same  drug  may  also  be  used  in  the 
form  of  a  lozenge.  Iron^  quinine,  and  other 
tonics,  change  of  air,  rest,  and  hygienic  measures 
of  all  kinds  are  likely  to  be  serviceable  for  cases  of 
aphonia  due  to  slight  laryngeal  catarrh.  When  the 
disorder  has  subsided,  precautionary  measures  should 
always  be  taken  in  order  to  lessen  the  susceptibility  of 


430  TREATMENT  OF  APHONIA. 


the  part.  A  daily  bath  of  tepid  waterj  in  which  a  little 
salt  has  been  dissolved_,  followed  by  friction  over  the 
whole  body;  flannel  next  the  skin;  outdoor  exercise 
adapted  to  the  patient's  state^  and  avoidance  of  over- 
heated rooms^  constitute  the  principal  measures  of  this 
character.  The  waters  of  Ems^  Selters,  and  Ober- 
salzbrunnen,  and  those  of  Aix-les-Bains  and  Marlioz, 
are  useful  in  many  cases  of  chronic  laryngeal  catarrh. 

In  functional  aphonia^  depending  on  inaction  of  the 
adductors  on  both  sides  and  consequent  non-approxi- 
mation of  the  vocal  cords  on  attempted  phonation,  the 
treatment  consists  in  stimulating  the  mucous  membrane 
of  the  larynx  in  various  ways.  Sir  M.  Mackenzie  has 
known  the  voice  to  be  restored  by  the  use  of  a  vapour 
impregnated  with  ammonia;  but  he  recommends  as 
more  efficacious  inhalations  of  oil  of  calamus  aromaticus 
and  of  creasote.  Either  40  minims  of  the  latter  or  five 
minims  of  the  former  are  mixed  with  20  grains  of 
mao-nesium  carbonate  and  one  ounce  of  water,  and 
used  at  a  temperature  of  140°.  Other  local  remedies 
are  stimulating  or  astringent  solutions,  such  as  nitrate 
of  silver  (5J  to  5J)  or  perchloride  of  iron  (sij  to  5J) 
applied  with  a  brush  to  the  interior  of  the  larynx,  or 
ntroduced    in    the   atomized    form.       All    the    above- 


TUB  A  TMENT  OF  A  PEON  I  A .  43 1 

mentioned  remedies  often  fail;  on  the.  other  hand^  Sir 
M.  Mackenzie*  states  that  endo-laryngeal  faradism  is 
ahnost  always  successful.  The  electric  current  should, 
however^  not  be  applied  until  any  hypersemia  of  the 
mucous  membrane  has  been  got  rid  of. 

In  using  faradism  to  the  larynx^  one  pole  is  passed 
within  the  glottis  and  placed  on  the  vocal  cords  and 
the  other  applied  externally  by  means  of  a  necklet. 
The  laryngeal  rheophore  is  so  constructed  that  the 
current  does  not  pass  until  the  metalled  point  or 
sponge  is  in  contact  with  the  vocal  cords.  It  is  kept 
in  this  position  for  a  second  or  two^  and  then  with- 
drawn, and  the  current  may  be  applied  five  or  six  times 
at  a  sitting.  A  distinct  laryngeal  sound  will  generally 
be  produced  on  the  first  application  of  endo-laryngeal 
faradism,  and  the  voice  will  get  stronger  on  each  suc- 
ceeding application.  After  it  has  been  restored,. faradism 
should  be  applied  externally  either  daily  or  every  other 
day  for  a  week  or  two  in  order  to  keep  up  the  effect, 
and  the  patient  should  be  directed  to  count  and  read 
aloud  several  times  daily  so  as  to  exercise  the  voice. 
In  hysterical  cases,  the  general   treatment  suitable  for 

*  "  Diseases  of  the  Throat  and  Nose/'  Vol.  i.,  p.  467. 


432  LARYNGEAL  HYPERESTHESIA. 

the  neurosis  should  be  put  in  force  at  the  same  time. 
These  cases  are  often  very  obstinate,  but  they  arc 
almost  always  cured  at  last,  even  when  the  aphonia 
has  existed  for  several  years. 

It  remains  to  consider  various  conditions  of  anaes- 
thesia, and  of  hypersesthesia  of  the  respiratory  nerves. 
The  former  is  of  very  rare  occurrence,  except  in  con- 
nection with  coma  as  a  result  of  poisoning,  and  in 
certain  cerebral  diseases.  Sir  M.  Mackenzie  states  that 
laryngeal  anaesthesia  as  a  serious  manifestation  appears 
to  be  confined  to  cases  of  diphtheritic  and  bulbar 
paralysis.  In  affections  of  the  former  class,  recovery  takes 
place  under  ordinary  tonic  treatment;  if  the  disorder 
becomes  chronic  the  application  offaradism  as  described 
in  the  previous  paragraph  is  likely  to  prove  successful. 

The  opposite  condition  of  hyperaesthesia  may  result 
from  catarrh,  from  the  irritation  produced  by  a  foreign 
body,  from  excessive  use  of  the  organ,  and  as  a  symptom 
of  general  nervous  irritability.  When  associated  with 
any  of  these  conditions  the  hyperaesthesia  is  liable  to 
be  complicated  by  a  troublesome  dry  cough  of  a  spas- 
modic character,  and  in  some  cases,  notably  In  hysterical 
subjects,  a  cough  of  this  kind  may  exist  without  per- 
version of  sensation. 


NEURALGIA   OF  THE  LARYNX.  433 

The  symptoms  of  laryngeal  hyperaesthcsia  are  a 
feeling  of  more  or  less  discomfort,  such  as  dryness  or 
rawness  of  the  part,  or  even  actual  pain  of  a  burning, 
pricking,  or  constrictive  character,  and  they  are  apt  to 
be  hicreased  by  coughing  and  swallowing,  while  spasm 
of  the  muscles  of  the  throat  and  larynx  is  sometimes 
superadded.  Some  patients  also  complain  of  various 
perversions  of  sensation,  e.g.^  of  a  feeling  as  though  a 
foreign  body  were  present  in  the  larynx,  whereas  nothing 
can  be  detected  after  the  most  careful  examination. 
Such  a  feeling  is,  of  course,  common  in  cases  in  which 
some  offending  body  has  been  removed,  and  it  is  apt  to 
last  for  some  time. 

Cases  of  true  neuralgia  of  the  larynx  have  been 
placed  on  record  by  Drs.  Handfield  Jones,  Graves, 
Mackenzie,  and  others,  but  the  affection  is  very  rare. 
In  Dr.  Graves'  case*  the  patient,  a  young  lady,  was 
originally  of  vigorous  constitution,  but  had  suffered  for 
some  time  from  menstrual  irregularity  and  hysteria. 
Antiphlogistic  treatment  of  all  kinds  had  been  tried 
without  avail ;  the  pain,  though  not  violent,  was  almost 
constant,  and  was  liable  to  occasional  aggravation.  The 

*  Graves'  *'  Clinical  Medicine,"  New  Syd.  Soc.  Ed.,  Vol.  i.,  p.  656. 

28 


434  LARYNGEAL  COUGH. 

feeling  was  one  of  distress  about  the  whole  region  of 
the  larynx  ;  there  was  no  external  tenderness,  and  the 
throat  was  healthy.  The  paroxysms  were  attended  by 
a  change  of  tone  and  weakness  in  the  voice.  It  was 
curious  that  in  this  case  the  employment  of  tonics 
(iron^  quinine,  and  arsenic)  had  the  effect  of  rendering 
the  attacks  perfectly  periodic. 

For  laryngeal  neuralgia,  Sir  M.  Mackenzie  recom- 
mends that  the  patient's  general  condition  should, 
when  necessary,  be  improved  by  such  measures  as 
change  of  air,  sea-bathing,  or  a  course  of  hydropathic 
treatment.  If  the  malady  appear  to  be  of  purely  local 
origin,  persistent  pencilling  of  the  laryngeal  mucous 
membrane  with  chloroform  and  morphine  would  seem 
to  be  the  best  means  of  curing  it.  Should  these  fail  to 
afford  relief,  Indian  hemp  and  bromide  of  potassium 
may  be  tried  either  separately  or  combined.  The  same 
remedies  would  probably  be  serviceable  in  cases  of 
perverted  sensibility  of  the  larynx. 

We  occasionally  meet  both  in  children  and  in  adults 
with  a  condition  in  which  a  troublesome  cough  is  the 
only  symptom.  It  is  not  accompanied  by  any  catarrh 
of  the  air  passages,  or  by  any  morbid  sounds  in  the 
chest  j  it  appears  to  be  a  purely  nervous  affection^  the 


LARYNGEAL  COUGS.  435 

result  of  some  morbid  condition  of  the  respiratory 
nerv^es.  The  cough  is  ahnost  always  dry  unless  a  violent 
paroxysm  gives  rise  to  the  formation  of  a  little  mucus; 
the  attacks  come  on  at  irresfular  intervals  and  last  for 

o 

indefinite  periods.  Sometimes  the  coughing  is  almost 
incessant  for  days,  being  checked  only  by  sleep  ;  in 
other  cases  it  comes  on  mainly  at  nighty  and  prevents 
the  sufferer  from  getting  any  sleep.  Its  character  varies ; 
the  sound  is  sometimes  hollow  and  loud,  sometimes  it 
resembles  the  barking  of  a  dog.  Sir  M.  Mackenzie 
records  the  case  of  a  young  lady  whose  "  cough  was  so 
loud  and  constant  that  her  friends  were  required  by  the 
proprietor  of  the  hotel  in  which  she  was  staying  to  have 
her  removed^  as  she  was  a  nuisance  to  all  the  other 
guests/'  In  such  cases  nothing  abnormal  can  be  de- 
tected with  the  laryngoscope,  nor  does  the  general 
health  suffer.  Trousseau,  however,  states  that  when 
the  disorder  is  much  prolonged  it  is  apt  to  affect  in- 
juriously the  general  health,  and  especially  when  the 
cough  is  complicated  with  obstinate  vomiting.  A  cough 
of  this  kind  is  not  unfrequent  in  hysterical  subjects,  and 
the  majority  of  the  patients  are  young  girls  between  16 
and  10  years  of  age.  There  is  sometimes  tenderness 
of  the   spine  between  the  scapulae  ;  and   in  other  cases 


436         COUGH  FROM  IRRITATION  OF  THE  FAR. 


the  cough  is  the  result  of  reflex  irritation  of  the  stomach 
or  intestines.  Tn  some  patients  the  cough  would  seem 
to  be  the  result  of  gouty  or  rheumatic  irritation. 

Certain  morbid  states  of  the  ear  are-apt  to  be  asso- 
ciated with  a  spasmodic  cough_,  and  this  organ  should 
never  be  neglected  in  cases  in  which  this  latter  symptom 
occurs.     Dr.  C.  Fox  has  published  a   case  of  a  woman 
aged   ^o,  who  for   eighteen   months    was    troubled  by 
laryngeal    irritation   and   cough ;   the  throat  and  lungs 
were  healthy  and  the  larynx  normal^  but  the  patient  was 
deaf  in  the  right  ear,  in  which  a  plug  of  wax  and  a  small 
ulcer  were  found.     The  cough    ceased  after  the  removal 
of  the  wax.     In  another  case  the  cough  was  associated 
with  the  presence  of  dead  bone  in  the  meatus.     The 
irritation  in  these  instances  is  conveyed  by  branches  of 
the  auriculo-temporal  of  the  fifth  to  the  vagus,  the  deep 
origin  of  which  in  the  medulla  oblongata  is  close  to  that 
of  the  sensory  root  of  the  fifth  nerve.     The  irritation  is 
referred  to  the    larynx  because  the  medulla  oblongata  is 
wont  to  receive    impressions   through   the  vagus  from 
that  organ.     Vomiting  and  cough  sometimes  arise  from 
the  state  of  the  teeth ;  dentists  know  that  irritation  of 
the  dental  branches  of  the  fifth  nerve  may  give  rise  to 
cough. 


TREATMENT  OF  SPASMODIC  COUGH.  437 

The  treatment  of  these  cases  of  spasmodic  cough  is 
apt  to  be  difficult,  but  the  complaint  generally  yields  to 
remedies.  Atropine  is  one  of  the  best  of  these;  it 
should  be  given  in  doses  of  gr.  xio  combined  with 
various  tonics,  such  as  iron,  quinine,  or  nitric  acid. 
Morphine  may  be  substituted  for  the  atropine,  should 
the  latter  fail  to  relieve.  Valerianate  of  zinc  and 
asafoetida  may  be  tried  for  hysterical  cases,  while  for 
rheumatic  and  gouty  subjects,  alkalies'  and  purgatives 
will  generally  be  serviceable.  When  the  cough  appears 
to  depend  upon  disorder  of  the  stomach  or  bowels,  the 
remedies  must  be  directed  to  these  parts.  Purgatives 
are  usually  indicated,  and  bismuth  with  hydrocyanic 
acid  and  henbane  will  probably  lessen  or  cure  the 
paroxysms  of  cough.  In  nervous  and  weakly  subjects, 
change  of  air,  travelling,  and  the  use  of  chalybeate  waters 
will  be  found  the  best  treatment.  There  is  one  other 
cause  of  spasmodic  cough  which  must  not  be  overlooked, 
namely,  tapeworm.  Dr.  Graves  records  the  case  of  a 
young  lady  whose  medical  attendants  (himself  among 
the  number)  had  exhausted  their  list  of  remedies,  but 
without  the  least  benefit  to  the  patient;  the  fits  of 
coughing  went  on  for  several  hours  with  extraordinary 
intensity ;  the   cough  was  dry,  extremely    loud,  hollow. 


438  TREATMENT  OF  SPASMODIC  COUGH. 

and  repeated  every  five  or  six  seconds^  night  and  day. 
This  patient  v^as  completely  cured  by  an  old  woman,  a 
servant  in  the  family,  who  suggested  a  dose  of  turpen- 
tine and  castor-oil  for  the  relief  of  an  attack  of  colic. 
The  result  was  the  passage  of  a  mass  of  tapeworm  and 
the  immediate  disappearance  of  every  symptom  of  pul- 
monary irritation. 

Another  functional  disorder  of  the  larynx  and  similar 
affections  of  the  lungs  will  require  special  chapters  for 
their  consideration.  All  these  disorders  are  characterized 
by  muscular  spasm  ;  in  the  one  case  affecting  the  larynx, 
and  in  the  other,  the  smaller  bronchi,  dyspnoea  being 
the  prominent  symptom  in  both  sets  of  cases. 


CHAPTER    II. 

LARYNGISMUS  STRIDULUS— LARYNGEAL  ASTHMA. 


Laryngismus  Stridulus — Nature  and  Causes — Age,  Rickets  and 
Scrofula,  Heredity,  Malnutrition — Exciting  Causes  of 
Attacks — Symptoms  of  a  Paroxysm — Spasm  of  Larynx — Carpo- 
pedal  Contractions,  Eclampsia — Anatomical  Changes  — 
Theories  as  to  Nature  of  Complaint — Sir  M.  Mackenzie's 
Views— Diagnosis — Prognosis— Treatment,  Prophylactic  and 
During  Attacks — Chloroform,  Musk,  Purgatives,  Bromide  of 
Potassium,  etc. 


Laryngismus   stridulus  is   a  somewhat  rare    com- 
plaint; but  inasmuch  as  it  appears  in  the  majority  of  cases 
to  be  a  pure  neurosis  of  the  larynx,  it  must  not  be  passed 
over.     It  consists  of  paroxysmal  attacks  of  difficulty  of 
breathing,  which  are  due  to   spasm   of  the  muscles  of 
the  glottis  and  of  the  diaphragm.     These  attacks  occur 
almost  exclusively  in  children ;  they  are  rare  before  the 
first  dentition  and   after  the  end  of  the  third  year,  the 
majority  of  the  patients  are  between  six  months  and  two 
years  old.     The  disorder  is  more  common  in  boys  than 
in   girls  j  rachitic    and    scrofulous    children   and    those 
brought  up   by   hand  are  especially  liable  to  suffer;  a 


440       SYMPTOMS  OF  LARYNGISMUS  STRIDULUS. 

large  proportion  of  the  cases  (from  80  to  90  per  cent.) 
are  the  subjects  of  rickets. 

Hereditary  predisposition  is  sometimes  traceable^and 
it  not  nnfrequently  happens  that  several  children  in  one 
family  are  similarly  affected.  Other  nervous  symptoms 
are  often  noticeable  in  the  subjects  of  laryngismus, 
such  as  restlessness,  abnormal  excitability,  disturbed 
sleep,  etc.  The  complaint  first  appears  in  some  cases 
when  attempts  at  weaning  are  being  made,  and  the 
child  is  fed  on  farinaceous  food  ;  it  is  more  common  in 
winter  than  in  summer,  and  in  cold  than  in  hot 
climates.  Ill-nourished  children,  living  in  badly-venti- 
lated rooms,  are  most  liable  to  attacks.  Epidemics  of 
laryngismus  have  been  occasionally  noticed. 

With  regard  to  the  exciting  causes  of  the  paroxysms, 
the  most  powerful  of  these  are  exposure  to  cold, 
gastric  and  intestinal  disorder,  dentition,  and  mental 
excitement  of  all  kinds.  Raising  the  child  in  the  arms 
and  letting  it  fall  through  the  air  will  often  excite  a 
paroxysm.  In  some  cases  even  the  first  attacks  appear 
to  be  of  spontaneous  origin.  Efforts  at  sucking,  loud 
screaming,  and  catarrh  of  the  larynx  are  frequent  pre- 
cursors of  a  paroxysm. 

Slight    premonitory    symptoms    are    sometimes    ob- 


SYMPTOMS  OF  LAEYNQISMUS  STRIDULUS.      441 

served,  but  the  attack  is  often  sudden,  and  may  occur  at 
any  time,  even  when  the  child  seems  quite  well  ;  it  is 
most  frequent  during  sleep,  from  which  the  child  sud- 
denly awakes  in  a  state  of  alarm.  It  is  seen  that  he  is 
unable  to  breathe  naturally  ;  the  respirations  are  irregu- 
lar, stridulous,  and  labouring,  each  being  a  little  longer 
than  the  preceding  one ;  the  head  is  thrown  back,  the 
nostrils  are  expandedj^  and  the  mouth  open,  and  the 
muscles  of  inspiration  act  convulsively,  and  at  last 
respiration  ceases.  The  child  either  closes  its  eyes  or 
stares  wildly  about  him,  the  face  becomes  pale  and  then 
livid,  the  heart  beats  rapidly  and  irregularly,  the  pulse 
is  small  and  frequent,  and  the  veins  of  the  neck  and 
head  are  prominent.  Percussion  shows  that  the  upper 
boundary  of  the  liver,  and  with  it  the  diaphragm,  are 
much  lower  than  normal.  Urine  and  f^ces  sometimes 
escape  voluntarily.  Symptoms  of  asphyxia  soon 
appear,  and  the  spasm  of  the  glottis  then  relaxes  ; 
improvement  is  ushered  in  by  a  deep  inspiration,  to 
which  a  loud  whistling  or  crowing  sound  is  generally 
superadded,  and  which  can  be  heard  at  some  distance. 
The  child  then  opens  its  eyes,  begins  to  cry,  and  after 
a  few  hurried  inspirations  appears  to  be  as  well  as 
usual. 


442       SYMPTOMS  OF  LARYNGISMUS  STRIDULUS. 

All  attack,  as  just  described_,  generally  lasts  for  a 
few  seconds  only,  but  it  may  be  prolonged  for  half  a 
minute  or  more.  In  some  cases  the  spasm  is  so 
slight  and  transient  that  it  is  detected  only  on  close 
examination  of  the  child.  The  complaint  sometimes 
comes  to  an  end  after  a  few  attacks ;  in  another  class, 
of  cases  the  attacks  are  spread  over  considerable  periods, 
and  occur  at  intervals  of  some  weeks  or  months,  and 
there  are  yet  other  cases  in  which  many  attacks  occur 
during  twenty-four  hours,  with  very  short  intervals, 
between  them.  It  often  happens  that  the  spasms  are 
not  confined,  to  the  constrictors  of  the  glottis,  but  like- 
wise involve  some  of  the  muscles  of  the  trunk  and 
extremities,  and  the  convulsive  movements  thus  caused 
may  precede,  accompany,  or  follow  the  spasm  of  the 
laryngeal  muscles.  These  movements  are  most  often 
observed  in  the  hands  and  feet ;  the  thumbs  are  drawn 
across  the  palms,  the  fingers  are  separated,  the  hands, 
are  flexed  on  the  wrists,  and  the  feet  are  flexed  and 
turned  outwards.  General  convulsions  and  loss  of  con- 
sciousness are  sometimes  superadded,  and  under  such 
circumstances  the  child  may  remain  very  weak  and 
prostrate  for  some  time  after  recovery.  Death  from 
suffocation  has  been  known  to  occur  during  an  attack ;, 


FA  THO GJENT  OF  LAR  YNGISMUS  STRID  UL  US.      443 

in  other  cases  the  fatal  issue  is  gradually  developed,  and 
is  preceded  by  symptoms  of  profound  debility. 

There  are  no  constant  anatomical  chano;es  discover- 
able  in  fatal  cases ;  that  is  to  sav^  there  is  nothing  to 
which  the  symptoms  can  always  be  referred.  Among  the 
various  morbid  conditions  that  have  been  found  in  fatal 
cases  the  following  are  the  most  remarkable  :  Changes 
in  the  bones^  due  to  rickets;  hydrocephalus;  enlarged 
thymus  ;  enlarged  bronchial  and  tracheal  glands  ; 
hyperaemia  of  the  brain  and  meningeal  haemorrhage; 
enlargements  and  fatty  infiltration  of  the  liver,  and 
swelling  of  the  lymphatic  follicles  in  the  intestines. 
Various  theories  have  been  })ut  forth  with  regard  to  the 
starting-point  of  the  symptoms.  Thus  they  have  been 
supposed  to  originate  in  the  brain,  as  a  result  of 
hyperaemia_,  hydrocephalus^  or  softening;  as  a  result  of 
rickets  and  craniotabes  and  consequent  pressure  on  the 
posterior  part  of  the  skull  and  brain ;  in  the  spinal  cord  ; 
as  a  result  of  enlargement  of  the  thymus  and  bronchial 
glands  ;  of  enlargement  of  the  liver ;  and  of  spasm  of  the 
diaphragm.  According  to  a  still  more  elaborate  theory 
the  ligament  in  the  jugular  foramen  which  separates  the 
jugular  vein  from  the  vagus  is  abnormally  flexible  and 
allows  the  vein  to  compress  the  nerve,  whereby  irritation 


444      DIAGNOSIS  OF  LARYNGISMUS  STRIDULUS. 

is  set  up  with  muscular  spasm  as  a  result.  None  of  these 
explanations^  however,  are  of  universal  applicability ;  a 
consideration  of  the  symptoms  and  of  the  post-mortem 
appearances  in  different  cases  shows  that  the  complaint 
is  sometimes  of  central,  sometimes  of  peripheral,  and 
sometimes  of  reflex  origin.  Sir  M.  Mackenzie  thinks 
that  '^the  weight  of  evidence  points  to  the  probable 
existence  of  molecular  changes  in  the  nerve-centres 
as  the  essential  cause  of  the  phenomena.  These 
changes  are  the  result  of  malnutrition  affecting  all 
the  structures  of  the  body.  .  .  .  Looking  at  the 
immediate  phenomenon  of  the  disease,  it  must  be 
regarded  as  a  spasm  of  a  limited  number  of  muscles 
brought  about  by  an  abnormal  condition  of  certain 
nerve-centres.  The  various  nerve-centres,  as  Dr. 
Hughlings  Jackson  has  pointed  out,  are  probably  not 
knit  together  so  closely  in  the  infant  as  in  the  adult, 
and  a  partial  convulsion — such  as  is  seen  in  laryngismus 
— points  to  an  imperfect  union  of  different  sections  of 
the  nervous  system." 

There  is  seldom  any  difficulty  in  diagnosing  attacks  of 
laryngismus  ;  the  a])sence  of  fever,  and  the  intermittent 
character  of  the  symptoms  serve  to  distinguish  it  from 
laryngeal   diphtheria  and    laryngitis.      The    attacks   of 


TEE  A  TMJENT  OF  LA  R  YNGISM  US  S  TRIB  UL  US.      445 

dyspnoea  which  terminate  in  crowing  or  whistling  in- 
spiration are  peculiar  to  this  complaint.  There  is  only  one 
other  affection,  viz.^  paralysis  of  the  abductors,  which 
is  liable  to  be  mistaken  for  it ;  but  the  former  is  rare  in 
children,  and  is  characterized  by  constant  dyspncea_, 
increased  on  exertion. 

The  prognosis  is  for  the  most  part  favourable,  but 
the  statements  of  different  authorities  on  this  point 
vary  considerably.  The  danger  increases  with  the 
youth  of  the  child,  the  duration  of  the  attacks,  and 
the  appearance  of  symptoms  of  eclampsia.  Cases 
due  to  defective  feeding,  provided  that  the  system 
be  not  too  much  reduced,  admit  of  favourable  prog- 
nosis. 

The  treatment  of  laryngismus  divides  itself  into  the 
measures  to  be  adopted  in  order  to  avert  attacks,  and 
those  suitable  for  cutting  short  or  lessening  the  severity 
of  a  paroxysm.  In  dealing  with  children  belonging  to 
a  family  in  which  the  complaint  has  already  shown 
itself,  prophylactic  measures  are  all-important.  The 
diet  should  receive  careful  attention  ;  it  should  be 
nourishing  and  non-irritating,  and  the  child  should  be 
protected  from  exposure  to  cold  and  excitement  of  all 
kinds.     If  there  be  evidences  of  scrofula  or  of  rickets. 


446       TRBA  TMENT  OF  LA  R  YNGISMUS  8  TRID  VL  US. 

the  treatment  suitable  for  these  conditions  should  be 
prescribed. 

Tn  dealing  with  individual  attacks,  the  child  should 
be  raised  and  placed  in  a  sitting  posture,  and  brought 
into  a  large  room  with  the  windows  open  so  that  he 
may  have  plenty  of  fresh  air ;  cold  water  should  be 
<Jashed  on  the  face,  neck,  and  breast,  and  ammonia  or 
acetic  acid  held  to  the  nose.  If  these  remedies  are  not 
successful,  the  child  should  be  placed  in  a  warm  bath 
while  cold  water  is  dashed  on  the  face  and  neck  as 
before.  Emetics  may  be  given  to  excite  vomiting,  and 
one  of  the  best  of  these  is  apomorphia,  injected  sub- 
cutaneously.  An  old-fashioned  method  of  producing 
this  result  is  to  tickle  the  fauces  with  a  feather,  and 
some  authorities  recommend  that  the  index  finger 
should  be  introduced  into  the  opening  of  the  larynx, 
and  an  attempt  made  to  raise  the  epiglottis.  Should 
the  spasm  continue,  chloroform  may  be  cautiously 
administered,  and  the  same  remedy  is  almost  always 
useful  whenever  there  are  repeated  attacks  in  quick 
succession.  Sir  M.  Mackenzie  recommends  that  when 
the  attack  is  over  and  the  child  is  able  to  swallow^,  the 
following  mixture  should  be  administered  : — R  Moschi, 
gr.  iss  ;  Sacch.  Alb.,  gr.  ij  ;  Pulv.  Acaciae,  gr.  ij  ;  Syrup. 
Aurantii  Flor.,  rrtxx;  Aquam  ad  5J. 


TREA  TMENT  O  F  LAR  YNGISMUS  S TRID  UL  US.      447 


In    order    to    prevent    recurrences,    every    endeavour 
should  be  made  to  ascertain  the  cause  of  the  attacks ; 
if  they  are   due  to  indigestion  or  to  constipation,   an 
emetic  or  purgative  will  be  indicated.     Calomel  or  grey 
powder  in  combination  with  rhubarb  and  soda  will  be 
found    useful,  and  the  musk  mixture   should  be   con- 
tinued for  24  hours.     If  the  fits  usually  occur  at  night, 
five  grains  of  chloral  should  be  given  to  the  child  before 
putting  it  to  bed,  and  in  most  cases  of  laryngismus  it  is 
well  to  prescribe  a  short  course  of  the  bromide  of  potas- 
sium in  doses  of  gr.  v  three  times  a  day.     If  the  child 
is  being  brought  up  by  hand  a   wet  nurse  should,    if 
possible,  be  obtained  ;  but  if  this  arrangement  be  im- 
practicable, its  diet  should  consist  exclusively  of  milk 
and  other  forms  of  animal  food.     Cod-liver  oil  is  useful 
in  most  cases,  and  change  of  air,  with  tepid  salt-water 
baths,    will    do   much    to    prevent    recurrences    of   the 
attacks.     When  the  latter  come  on   in   children  who 
are  being  weaned,  the  breast  must  again  be  given  to 
them ;    but  if  the  spasm   appear   during    sucking,   at- 
tempts must  be  made  to  feed  the  child  with  a  spoon. 


CHAPTER  III. 

ASTHMA. 


Asthma,  Meaning  of  Term  —  Causes — Age,  Constitutkjnal  Con- 
ditions, Weather,  and  Climate  —  Idiopathic  and  Sympto- 
matic Asthma — Bronchial  and  Nasal  Affections — Dust  and 
Emanations  of  Various  Kinds  —  Abdominal  Disorders  — 
Renal  Affections — Asthma  and  Gout — Symptoms  of  Asthma — 
Objective  Symptoms  Disking  an  Attack — Pathogeny — Sequels 
— Diagnosis — Prognosis — Treatment  during  the  Paroxysm. 
Narcotics  and  Antispasmodics  —  During  the  Intervals  — 
Removal  of  Causes — Inhalation  of  Oxygen  and  of  Con- 
densed Air — Change  of  Air — Treatment  of  Gouty  Cases — 
Purgatives — Alkalies — Iodide  of  Potassium — Electricity. 


The  term  asthma  is  apt  to  be  somewhat  vaguely  appHed 
to  express  attacks  of  difficulty  of  breathing  in  general^ 
and  patients  suffering  from  chronic  bronchitis,  emphy- 
sema, or  heart-disease  are  often  regarded  as  asthmatic. 
The  two  disorders,  however,  bronchitis  and  asthma,  are 
perfectly  distinct,  and  either  may  exist  without  the 
other.  Bronchial  asthma,  which  I  am  now  about  to 
discuss,  consists  of  attacks  of  difficulty  of  breathing 
which  depend  upon  the  periodical  recurrence  of  spas- 
modic contraction  of  the  bronchial  muscles.  The  pneu- 
mogastric  is  the  nerve  distributed  to  these  structures. 


CAUSi:S  OF  ASTHMA. 


449 


and  inasmuch  as  in  cases  of  essential  asthma^  anato- 
mical chano'es  which  would  account  for  the  attacks  are 
not  to  be  discovered^  the  disorder  must,  at  least  for  the 
present,  be  regarded  as  a  neurosis  of  the  nerve  just 
mentioned. 

Nothing  of  a  very  definite  character  can  be  stated 
with  reference  to  the  causes  of  asthma;  the  complaint  is 
more  common  in  the  well-to-do  than  in  those  differently 
situated  ;  males  are  more  often  affected  than  females  in 
the  proportion  of  two  to  one ;  as  age  advances  the 
numbers  become  more  nearly  equal.  The  majority  of 
the  sufferers  are  under  40  years  of  age,  and  children 
form  a  comparatively  large  contingent;  in  many  cases 
the  first  attack  occurs  during  the  first  decade.  Heredity 
plays  a  certain  part  in  the  causation  of  asthma,  and  it  is 
not  uncommon  to  find  several  members  of  the  family 
suffering  from  the  complaint  or  from  other  forms  of 
nervous  disorder.  With  regard  to  constitutional  con- 
ditions, the  disorder  is  said  to  be  more  frequent  amono- 
the  subjects  of  rickets,  scrofula,  anaemia,  and  those  of  a 
decidedly  nervous  tendency.  Some  forms  of  asthma 
are  affected  as  regards  prevalence  by  climate  and  season  ; 
cold  and  damp  weather  produces  bronchial  catarrh, 
which    in  its   turn    may   lead   to    a   development    of   a 

29 


450 


CAUSES  OF  ASTHMA. 


symptomatic  asthma.  Change  of  weather  and  of  loca- 
hty  has  a  different  influence  on  different  asthmatic 
subjects.  Most  of  them  are  reheved  by  a  moist  air  and 
a  residence  in  low-lying  places ;  but  peculiarities  of  an 
opposite  kind  are  sometimes  noticed.  Many  asth- 
matic patients  feel  decidedly  better  in  London  than  in 
country  air. 

Two  forms  of  the  complaint  have  to  be  considered, 
w\z.,  the  idiopathic  or  essential  asthma,  and  that  which  is 
symptomatic  or  of  reflex  origin.  In  the  former  of  these  no 
obvious  cause  can  be  demonstrated ;  in  the  latter  there 
are  lesions  of  organs  more  or  less  distant^  the  irritation 
resulting  from  which  is  propagated  to  the  pneumogastric 
nerve^  with  spasm  of  the  bronchial  muscles  as  a  result. 
The  existence  of  such  a  connection  is  proved  by  those 
cases  in  which  the  attacks  cease  after  the  cure  of 
the  lesions  by  which  they  were  excited.  In  rare 
cases,  changes  have  been  found  in  the  nuclei .  of 
the  vagus  itself,  and  in  other  parts  of  the  brain  and 
cord,  but  the  significance  of  such  lesions  is  doubtful. 
Not  a  few  cases,  however,  have  been  reported  in  which 
the  nerve  itself  was  compressed  by  various  growths, 
such  as  enlarged  lymphatic  glands  either  in  the  neck  or 
connected  with  the  bronchi,  or  by  an  enlarged  thynius 


CA  USES  OF  AS THMA .  45 1 

gland.  Enlargement  of  the  bronchial  glands  is  a  fre- 
quent result  of  measles,  scarlet  fever_,  and  whooping 
cough  in  children,  and  attacks  of  asthma  are  thus  liable 
to  be  produced  in  these  subjects.  Swellings  of  a  like 
character  are  somewhat  frequent  in  scrofulous  and 
rachitic  cases. 

The  mucous  membrane  of  the  nose  or  of  the  naso- 
pharynx is  the  spot  whence  the  irritation  proceeds  in 
another  class  of  cases,  and  this  condition  of  morbidly 
increased  irritability  may  exist  either  with  or  without 
definite  changes.  In  most  persons,  cough  is  excited  by 
irritating  the  terminations  of  the  fifth  nerve  in  the  nasal 
mucous  membrane,  and  there  are  many  curious  idio- 
syncrasies in  respect  of  the  irritability  of  this  part. 
Thus  in  some  persons  a  severe  attack  of  bronchial 
asthma  is  brought  on  by  inhaling  powdered  ipecacuanha; 
and  in  others  by  the  pollen  of  grasses,  oats,  and  maize. 
Certain  chemical  irritants  have  a  similar  power  in  some 
cases  ;  thus  chlorine  gas  and  even  perfumes  and  emana- 
tions of  various  kinds,  such  as  the  scents  of  violet, 
heliotrope,  and  peppermint,  are  sufficient  to  provoke 
symptoms  of  asthma.  Emanations  from  animals  are 
said  to  produce  the  same  effect  in  some  persons.  Such 
•causes  would  be  more  likely  to  prove  operative  in  persons 


452  CAUSES  OF  ASTHMA. 

with  a  tendency  to  the  disorder^  than  where  such  a  pro- 
chvity  was  absent. 

Attacks  of  asthma  are  not  unconnnon  in  cases  of 
nasal  polypus  and  other  affections  of  the  nose,  the  nasal 
nerves  being  in  a  condition  of  abnormal  reflex  irritability. 
The  attacks  subside  after  removal  of  the  growths  ;  but 
they  sometimes  recur  with  any  fresh  development.  Affec- 
tions of  the  inferior  turbinate  bone  are  especially  liable 
to  lead  to  these  consequences,  and  chronic  rhinitis  of 
an  atrophic  character  has  been  observed  to  be  attended 
by  symptoms  of  asthma.  With  regard  to  throat  affec- 
tions, a  granular  condition  of  the  pharynx  and  even 
enlarged  tonsils  have  occasioned  similar  attacks.  I 
have  known  two  cases  of  asthma  in  children  the  sub- 
jects of  enlarged  tonsils ;  removal  of  the  latter  was 
followed  by  cessation  of  the  asthmatic  attacks.  Bron- 
chial asthma  often  complicates  bronchitis;  but  the  dis- 
order must  be  distinguished  from  the  attacks  of  dyspnoea, 
so  common  in  the  latter  complaint.  Similar  symptoms 
are  likewise  observed  in  many  cases  of  heart  disease. 

Disorders  of  the  abdominal  organs  are  potent  causes 
of  asthmatic  attacks  in  those  predisposed  to  them. 
Thus  severe  paroxysms  are  often  occasioned  by  over- 
distension of  the  stomach  whether  by  food  or  by  the 


CAUSES  OF  ASTHMA.  453 

gaseous  products  of  fermentation,  and  in  some  persons 
such  a  result  is  occasioned  by  the  ingestion  of  certain 
articles  of  food  even  in  moderation.  Constipation  and 
the  presence  of  worms  are  other  causes  of  this  character. 
Asthma  is  sometimes  connected  with  disorders  of  the 
uterus  and  ovaries,  and  hence  attacks  are  not  unfrequent 
in  hysterical  and  nervous  women.  In  some  women,  the 
symptoms  come  on  during  pregnancy  and  cease  after 
delivery.  Certain  peculiarities  are  sometimes  exhibited 
by  hysterical  subjects  ;  thus  in  the  case  of  a  girl  aged 
tvventv,  with  marked  hysteria,  attacks  of  asthma  are 
apparently  brought  on  by  taking  a  cup  or  two  of  tea. 
Symptoms  of  asthma  are  sometimes  associated  with 
renal  disorders  ;  in  uraemia,  the  difficulty  of  breathing  is 
caused  by  the  excessive  amount  of  urea  and  other 
urinary  constituents  present  in  the  blood.  A  similar 
causation,  uric  acid  being  the  offending  material,  is  seen 
in  cases  of  gouty  asthma.  The  connection  between 
the  bronchial  disorder  and  the  gouty  diathesis  is  shown 
by  the  fact  that  the  former  either  subsides  or  remits  on 
the  development  of  the  articular  inflammation.  It  is 
said  that  asthma  is  sometimes  associated  with  eczema ; 
in  such  cases  the  two  affections  have  probably  a  common 
origin,  both  being  symptoms  of  the  uric  acid  diathesis. 


454  SYMPTOMS  OF  ASTHMA. 

Lastly,  symptoms  of  asthma  are  occasionally  seen  in 
cases  of  chronic  poisoning  by  lead  and  mercury. 

Difficulty  of  breathing  constitutes  the  principal  sym- 
ptom of  attacks  of  bronchial  asthma,  the  expiratory 
movements  being  especially  affected  and  the  lungs 
remaining  in  a  condition  of  acute  over-inflation. 

Attacks  of  asthma  occur  either  with  or  without  pre- 
monitory symptoms.  In  the  former  case,  the  patient 
complains  of  general  malaise,  a  feeling  of  pressure  in 
the  head,  an  uncontrollable  desire  to  yawn,  eructations, 
vomiting,  distension  of  the  abdomen,  or  chilliness.  In 
other  cases  there  are  signs  of  catarrh  of  the  conjunctiva, 
and  nasal  mucous  membrane,  the  bronchial  tubes  becom- 
ing gradually  involved.  Some  patients  know  that  an 
attack  is  impending,  because  they  have  exposed  them- 
selves to  influences  against  which  their  experience  has 
.warned  them. 

Paroxysms  of  asthma  exhibit  many  peculiarities,  and 
among  these  that  of  being  most  frequent  in  the  early 
morning  is  one  of  the  most  marked.  The  patients  are 
often  aroused  from  their  sleep  with  a  feeling  of  suffoca- 
tion, which  rapidly  becomes  worse;  violent  attempts  are 
made  to  obtain  air;  many  patients  get  before  an  open 
window  and  expose  themselves  to  a  cool  draught.   At  this 


SYMPTOMS  OF  ASTHMA.  455 

Stage  whistling  rhonchi  are  heard,  and  are  sometimes  so 
loud  as  to  be  audible  throu2:hout  the  house.  The  attack 
after  lasting  a  variable  time,  during  which  the  condition 
of  the  patient  may  have  been  most  alarming,  gradually 
subsides.  The  breathino;  becomes  more  free,  cous^h 
with  a  muco-purulent  expectoration  sets  in,  the  respira- 
tory movements  are  less  and  -  less  embarrassed,  and 
yawning,  eructations,  or  vomiting  are. apt  to  take  place. 
The  skin  during  an  attack  feels  cool  to  the  touch,  but 
the  thermometer  indicates  some  rise  of  temperature. 
The  pulse  is  small,  generally  hard  and  frequent.  The 
attacks  varv  in  duration  from  a  few  minutes  to  several 
hours,  and  they  may  occur  daily  or  even  several  times  a 
day^  or  at  longer  or  shorter  intervals,  which  are  sometimes 
regular. 

Certain  of  the  symptoms  require  a  more  detailed 
examination,  and  especlallv  the  respiratory  acts.  The 
alteration  is  mainly  in  the  expiration,  but  the  auxiliary 
muscles  for  inspiration  are  also  called  into  play.  The 
action  of  the  expiratory  muscles  is  very  marked  ;  the 
recti  abdominis  and  the  transverse  muscles  are  forcibly 
contracted  during  expiration.  The  time  occupied  by 
the  two  acts  shows  considerable  alterations  ;  inspiration 
is  slower  than  usual,  but  the  expiratory  act  is  very  much 


456  SYMPTOMS  OF  ASTHMA. 


prolonged.  It  may  be  three  times  as  long  as  that  of 
inspiration;  the  number  of  respirations  is,  therefore, 
much  reduced^  and  the  pause  between  the  two  acts  is 
altoo^ether  absent.  The  distended  luno;  prevents  the 
movements  of  the  heart  from  being  visible. 

The  position  and  aspect  of  the  patient  are  very 
characteristic.  He  sits  up,  supporting  himself  on  his 
elbows,  with  his  mouth  open^  his  shoulders  elevated, 
and  his  head  thrown  back ;  his  countenance  betrays 
intense  anxiety.  The  sterno-mastoid  muscles  project, 
like  hard  cords,  from  the  sides  of  the  neck.  Indications 
of  cvanosis  soon  show  themselves;  the  cervical  veins 
form  hard,  blue  cords,  and  the  eyes  appear  to  be  starting 
from  their  sockets ;  sometimes  blood  escapes  beneath 
the  conjunctiva.  The  face  is  covered  with  copious  per- 
spiration, and  if  the  attack  lasts  for  any  length  of  time, 
the  countenance  becomes  livid  and  pale,  and  there  is 
more  or  less  insensibility  with  delirium  and  muscular 
twitchings. 

The  thorax  on  examination  is  found  to  be  greatly 
expanded  ;  the  percussion  sound  all  over  the  chest  is 
loud,  deep,  and  tympanitic.  In  the  lower  regions  of 
the  thorax,  especially  behind  and  at  the  sides,  there  is  a 
modification  of  the  tympanitic  note,  described  by  Prof. 


SYMPTOMS  OF  ASTHMA.  457 

Biermer,  of  Zurich,  as  the  bandbox  note,  from  its 
leseniblance"  to  the  sound  given  by  such  a  box  when 
struck  j  it  depends  upon  the  increased  tension  of  the 
alveolar  tissue.  On  further  examination  the  borders  of 
the  lungs  are  found  to  extend  lower,  and  also  further 
inwards  towards  the  sternum  than  under  normal  circum- 
stances, and  they  are  little  if-  at  all  affected  by  the 
respiratory  acts.  The  upper  margin  of  the  liver  is  one 
or  two  intercostal  spaces  lower  than  natural,  and  the 
cardiac  dulness  is  considerably  reduced.  These  changes 
likewise  remain  unaffected  by  respiration,  but  when  the 
attacks  cease  the  lungs  return  to  their  normal  positions, 
unless  emphysema  has  been  set  up.  The  diaphragm  is 
considerably  depressed  and  moves  but  little  during 
respiration.  Its  position  is  the  result  not  of  tonic 
spasm  of  its  fibres,  but  of  an  increase  in  the  amount  of 
air  in  the  lungs,  an  excessive  inflation,  so  to  speak,  and 
this  depends  upon  the  spastic  contraction  of  the 
bronchi. 

On  auscultation  during  an  attack  the  vesicular  respi- 
ratory murmur  is  either  altogether  absent  or  else 
concealed  by  the  sibilant  or  sonorous  rhonchi.  When 
the  spasm  is  slight  the  sibilant  rhonchi  are  almost 
•equally  loud  in  both  acts ;   in  more  marked   spasm  they 


4S8  SYMPTOMS  OF  ASTHMA. 

are  louder  in  expiration^  but  when  the  spasm  has 
reached  its  height  they  are  no  longer  audible^  because 
the  interchange  of  air  has  been  reduced  to  a  minimum, 
and  the  conditions  are  absent  for  the  production  of  any 
respiratory  murmur  in-  the  finer  air-passages.  For  the 
most  part  we  hear  a  short  and  weak  whistle  in  inspira- 
tion, and  a  longer  and  stronger  in  expiration  (Biermer). 
As  the  attack  passes  off  the  sibilant  rhonchi  gradually 
cease  and  give  place  to  mucous  rales.  While  the  attack 
is  at  its  height  the  patients  speak  in  a  hoarse,  low  voice, 
and  often  with  great  difficulty,  so  that  they  prefer  ta 
make  signs  for  anything  they  require.  The  heart- 
sounds  may  be  almost  inaudible,  owing  to  the  manner 
in  which  the  organ  is  covered  up  by  the  lungs. 

Expectoration  is  for  the  most  part  absent  during  the 
attack,  but  at  its  termination  cough  is  apt  to  set  in,  and 
is  accompanied  by  the  expectoration  of  more  or  less 
greyish-white,  tenacious  and  frothy  matter,  which  is 
sometimes  thick,  like  gelatine.  Besides  various  flakes, 
threads,  and  little  clots,  the  expectoration  often  contains 
twisted  threads,  greyish  or  yellowish  in  colour,  and 
somewhat  regular  in  form.  Their  length  is  from  two 
to  three  centimetres,  and  sometimes  more,  and  the 
largest  is  about  a  millimetre  wide ;   they  are  supposed 


PATnOGENY  OF  ASTHMA.  459 

to  orisfinate  in  the  finest  divisions  of  the  bronchial 
tubes,  and  to  be  the  results  of  exudation.  Curious 
octahedral  crystals_,  similar  to  those  met  with  in  the 
tissues  of  leukaemic  subjects,  are  sometimes  found  in 
the  expectoration.  Their  chemical  composition  is 
unknown,  but  thev  are  not  peculiar  to  asthma ;  they 
have  been  found  in  cases  of  bronchial  catarrh  and 
phthisis.  Oxalate  of  lime  crystals  also  occur  in  the 
expectoration. 

Pathogeny.  Several  explanations  have  been  offered 
as  to  the  manner  in  which  a  paroxvsm  of  bronchial 
asthma  is  induced.  The  important  p<:)int  to  be  borne 
in  mind  is  that  nervous  influences  are  not  onlv  present, 
but  play  the  most  considerable  part  in  causing  the 
attacks.  The  following  would  appear  the  most  probable 
view  :  the  smooth  muscular  fibres  in  the  middle-sized 
and  smaller  bronchi,  to  which  the  pneumogastric  nerve 
is  distributed,  are  thrown  into  a  state  of  tonic  contrac- 
tion ;  the  interchange  of  air  is  thus  rendered  not  im- 
possible, for  then  life  would  cease,  but  extremely 
difficult.  The  powerful  muscles  of  inspiration  are  able 
to  overcome  the  increased  resistance,  but  the  expiratory 
muscles  fail  in  this  respect.  Their  action  is  hindered 
by  the  fact  that  the  pressure  in  expiration  acts  not  only 


460  PA  THO  GBNY  OF  A  STRMA . 

from  below  upwards,  but  also  in  two  other  directions,  viz., 
from  the  sides  towards  the  middle  line  and  from  before 
backwards.  Hence  the  minuter  bronchi,  together  with 
the  alveoli,  are  laterally  compressed;  and  inasmuch  as 
both  parts  are  under  the  same  pressure,  the  escape  of 
air  from  the  one  into  the  other  can  take  place  only  as 
the  result  of  pressure  exercised  from  below  upwards. 
The  lateral  pressure  may,  however,  be  so  strong  that 
the  walls  of  the  finer  ramifications  of  the  tubes,  in 
which  all  traces  of  cartilage  are  wanting,  are  compressed 
so  as  to  meet,  and  in  such  a  case  the  resistance  would 
be  more  than  could  be  overcome  by  the  abdominal 
pressure.  If  the  interchange  of  air  were  reduced  below 
a  certain  point,  death  would,  of  course,  follow  ;  but 
here  the  self-regulatory  power  of  the  respiratory  act 
comes  into  play,  the  accumulation  of  carbonic  acid  in 
the  blood  acts  upon  the  vagus  centres,  the  spasm  of  the 
bronchial  muscles  is  relaxed,  and  expiratory  acts  are 
once  more  possible. 

In  addition  to  the  spasm,  the  fluxionary  hyperaemia 
of  the  bronchial  and  alveolar  vessels  increases  the 
obstacles  to  the  admission  of  air,  and  diminishes  the 
extent  of  surface  from  which  interchange  of  gases  takes 
place.     Such  hyperaemia  may  be  inferred  to  exist  from 


PA  THO  GENT  OF  A  STEM  A .  46 1 

the  fact  that  in  some  cases  of  asthma  a  watery  fluid 
exudes  from  the  nose  and  eyes,  both  which  parts  are 
obviously  hyperaemic.  This  condition  would  still  further 
impede  the  exchange  of  air  as  occurs  in  capillary 
bronchitis.  It  is  also  highly  probable  that  when  the 
finer  air-tubes  are  much  contracted  the  forcible  inspira- 
tory movements  exercise  an  aspirating  effect  upon  the 
contents  of  the  alveolar  vessels^  and  that  thus  cedema 
is  set  up.  Even  when  the  degree  of  spastic  contraction 
is  small,  any  swelling  of  the  bronchial  mucous  mem- 
brane will  suffice  to  induce  the  phenomena  of  asthma. 

With  regard  to  the  position  of  the  diaphragm,  it  is 
due  to  the  over-distension  of  the  lungs,  but  the  suo'o-es- 
tion  has  been  made  that  this  muscle  is  thrown  into  a 
state  of  clonic  spasm  by  reflex  action  transmitted  by 
the  vagus  to  the  phrenic  nerve.  Such  a  condition 
cannot  be  regarded  as  that  of  tetanus ;  it  is  much 
more  probable  that  the  muscle  is  for  the  time  in  the 
condition  it  occupies  during  inspiration,  as  a  result^  it 
may  be^  of  irritation,  and  that  during  expiratory  efforts 
only  very  little  relaxation  occurs.  The  bronchial  spasm 
must  be  regarded  as  the  predominating  factor  ;  its 
existence  explains  the  alterations  in  the  respiratory  acts, 
the  distension  of  the  lungs^  the  occurrence  of  various 


46 2  DIA  GNOSIS  OF  A  STRMA . 

kinds  of  rhonchi^  and  the  position  of  the  diaphragm. 
It  may,  however,  be  admitted  that  in  some  cases  a 
certain  degree  of  spasm  of  this  muscle^  and  likewise  of 
iiuxionary  hypersemia,  contribute  toward  the  develop- 
ment of  the  symptoms. 

Asthma  rarely  continues  for  any  length  of  time 
without  giving  rise  to  organic  affections  of  the  lungs 
and  heart.  Emphysema  is  the  most  common  sequela ; 
as  a  result  of  the  constant  distension  of  the  alveoli^ 
their  elasticity  is  lost,  and  they  become  permanently 
dilated.  Rupture-  of  their  walls  is  also  apt  to  take 
place,  with  the  formation  of  large  air-sacs  as  a  result. 
Chronic  catarrh  of  the  tubes  is  a  frequent  accompani- 
ment. With  regard  to  the  heart,  the  right  ventricle  is 
apt  to  become  hypertrophied  and  dilated,  in  consequence 
of  the  obstruction  during  the  attacks  to  the  course  of 
the  blood  through  the  lungs. 

The  diagnosis  of  bronchial  asthma  is  for  the  most 
part  easily  made ;  there  can  be  no  doubt  as  to  the 
nature  of  the  complaint  in  typical  cases.  The  sudden 
and  paroxysmal  character  of  the  attacks ;  their  most 
frequent  occurrence  in  the  latter  half  of  the  night ;  the 
expiratory  dyspnoea,  with  the  whistling  and  wheezing 
sounds  that  accompany  it;  the  signs  of  over-distension 


DIAGNOSIS  OF  ASTHMA.  463 


of  the  lung ;  the  catarrhal  expectoration  at  the  close  of 
the  attack_,  and  the  freedom  from  disorder  during  tlie 
intervals  constitute  a  group  of  features  not  met  with  in 
any  other  complaint.  Asthmatic  attacks  may,  how- 
ever^ comphcate  various  affections  of  the  heart  and 
lungs,  and  in  some  affections  of  the  nervous  system 
attacks  of  difficulty  of  breathing  are  apt  to  occur. 

Dyspnoea  frequently  compUcates  bronchitis,  but  the 
attacks  do  not  come  on  suddenly,  and  are  usually 
referable  to  a  distinct  cause,  such  as  an  extension  of 
the  original  disorder.  Moreover,  in  bronchitis  the 
state  of  the  lungs  in  the  intervals  is  sufficient  to  de- 
termine the  nature  of  the  case.  The  two  conditions 
may,  of  course,  co-exist;  either  having  preceded  the 
other. 

Attacks  of  shortness  of  breath  are  common  also  in 
emphysema,  but  they  do  not  come  on  suddenly  and 
unexpectedly.  On  the  other  hand,  they  are  noticed  to 
be  an  exaggeration  of  the  patient's  ordinary  condition, 
they  can  generally  be  induced  by  exertion,  and  they 
subside  only  in  an  incomplete  manner.  On  examining 
the  chest  daring  the  intervals,  evidences  of  changes  in 
the  lung-structure  will  be  easily  discovered.  Asthmatic 
patients  often  become  emphysematous. 


464  DIAGNOSIS  OF  ASTHMA. 


Attacks  of  dyspncea  are.  common  in  patients  suffering 
from  diseases  of  the  heart ;  in  these  cases  they  are  apt 
to  be  provoked  by  exertion  and  excitement.  There  are 
also  the  various  murmurs  and  the  condition  of  the 
patient  between  the  paroxysms^   to  determine    the   dia- 


gnosis. 


Similar  attacks  occur  in  croup,  and  as  the  result  of 
the  presence  of  foreign  bodies  in  the  larynx  or  trachea, 
but  in  all  these  cases  the  difficulty  of  breathing  will  be 
connected  with  the  inspiratory  acts,  and  the  lungs  are 
incompletely  filled.  Expiration,  on  the  other  hand,  in 
the  absence  of  complications  is  performed  quickly,  and 
with  comparative  ease,  and  the  chest  resumes  its  normal 
form. 

Spasm  of  the  diaphragm  sometimes  occurs  in  hys- 
terical subjects,  and  the  effects  closely  simulate  an 
attack  of  asthma.  The  thorax  remains  for  some  seconds 
in  the  inspiratory  position  j  the  inspirations  are  short 
and  spasmodic,  like  the  movements  in  hiccough ;  the 
epigastrium  projects;  the  heart  is  drawn  downwards, 
and  towards  the  median  hne,  and  the  patient  complains 
of  pain  in  the  region  of  the  diaphragm.  . 

Another  condition,  simulating  asthma,  likewise  occurs 
in    hysterical    subjects,   viz.,   paralysis  of  the  posterior 


PROGNOSIS  OF  ASTHMA.  465 

crico-arytenoid  muscles.  The  difficulty  is,  however, 
connected  with  inspiration,  the  current  of  air  causing 
the  vocal  cords  to  approximate,  thus  preventing  its 
ingress.  The  dyspnoea  in  such  cases  is  continuous 
rather  than  parox3''smal.  It  is  possible  that  attacks  of 
nightmare  may  be  mistaken  for  asthma  when  the 
dyspnoea  occurs  only  during  sleep,  and  the  physician 
has  no  opportunity  of  noticing  the  course  of  the  sym- 
ptoms, but  has  to  depend  upon  the  statements  of  the 
patient.  When  due  to  asthma,  the  dyspnoea  increases 
after  the  patient  wakes,  whereas  it  soon  ceases  when 
consciousness  is  restored  in  cases  of  ni2:htmare. 

The  prognosis  of  asthma  in  general  is  much  more 
favourable  than  might  be  supposed  from  the  severity 
of  the  symptoms.  Death  very  rarely  occurs  during  a 
paroxysm  ;  for  when  the  excess  of  carbonic  acid  in  the 
blood  reaches  a  certain  degree,  the  spasm  of  the  bron- 
chial muscles  gives  place  to  a  condition  of  paralysis. 
With  regard  to  the  cure  of  the  complaint,  this  depends 
upon  the  condition  to  which  the  symptom  is  due ;  if 
removable,  the  attacks  may  be  expected  to  cease.  Age 
is  a  consideration  in  the  prognosis  ;  the  younger  the 
patient  the  greater  the  probability  of  recovery.  In  not 
a  few  cases  the  complaint  continues  throughout  life,  the 

30 


466  TREATMENT  OF  ASTRMA. 

results  depending  in  great  measure  upon  the  circum- 
stances and  habits  of  the  patient.  With  the  develop- 
ment of  complications  the  prognosis  becomes  more  and 
more  unfavourable. 

The  treatment  of  asthma  divides  itself  into  a  con- 
sideration of  the  measures  to  be  adopted  during  a 
paroxysm,  and  of  those  which  should  be  taken  during 
the  intervals  in  order  to  prevent  recurrences.  When  a 
paroxysm  is  impending  the  patient^s  clothes  should  be 
freely  loosened  about  the  neck  and  chest,  and  cool,  pure 
air  admitted  into  the  room.  As  a  matter  of  course, 
all  objects,  the  presence  of  which  is  likely  to  induce  an 
attack,  should  be  at  once  removed.  Some  patients  find 
by  experience  that  a  cup  of  strong  coffee,  a  cigar,  or 
a  few  pieces  of  ice  will  afford  much  relief.  In  one  case 
recorded  by  Trousseau  benefit  was  obtained  by  lighting 
up  the  room  with  several  lamps. 

With  regard  to  medicines,  certain  of  the  narcotics 
yield  very  satisfactory  results,  and  the  most  potent  of 
them  is  chloral,  which  should  be  given  in  full  doses, 
say  30  grains  at  once,  or  in  half  this  quantity,  to  be 
repeated  in  half-an-hour.  These  large  doses  are  much 
more  efficacious  than  small  ones.  Instead  of  chloral 
we  may  have  recourse  to  hypodermic  injections  of  mor- 


TEJSATMENT  OF  ASTHMA.  4<n 


phine,  gr.  ^-J,  or  the  same  drug  may  be  given  inter- 
nally. Other  narcotics  have  also  been  found  efficacious 
— among  them  belladonna,  cannabis  indica,  lobelia,  and 
cocaine.  Atropine  is  said  to  paralyze  the  constrictor 
fibres  of  the  vagus  which  supply  the  bronchial  muscles. 
Good  results  have  been  obtained  from  cocaine  injected 
subcutaneously. 

Anti-spasmodics  may  likewise  be  administered  by 
inhalation,  but  they  are  seldom  so  efficacious  as  chloral. 
Chloroform _,  amyl  nitrite,  sulphuric  aether,  ammonia, 
hydriodic  aether,  and  oil  of  turpentine,  are  used  for 
inhalation  purposes  ;  and  other  remedies  similarly 
employed  are  arsenical  cigarettes,  the  fumes  of  nitrate  of 
potassium,  stramonium  cigars,  the  vapour  of  camphor, 
etc.  Some  patients  are  benefited  by  cigars  composed  of 
belladonna,  stramonium,  henbane,  and  opium,  and  by 
others  to  which  nitre  is  added.  The  alcoholic  extract 
of  grindelia  robusta  is  likewise  used  in  a  similar  manner, 
and  it  is  sometimes  given  internally  ;  half-a-teaspoonful 
of  the  fluid  extract  is  stated  to  have  afforded  almost 
instantaneous  relief  in  several  cases  of  asthma  occurring 
in  old  persons.  Whenever  there  are  indications  of  a 
distended  stomach  in  connection  with  the  attack,  an 
emetic  should,  of  course,  be  administered ;  sulphate  of 


468  TREATMENT  OF  ASTHMA. 

zinc  or  mustard  will  answer  this  purpose,  but  the  sub- 
cutaneous injection  of  aponiorphine  gr.  ^  will  prove 
more  efficacious. 

In  order  to  fulfil  the  second  indication,  viz.,  to  prevent 
recurrences^  a  careful  inquiry  should  be  made  into  any 
possible  causes  of  the  complaint;  and  should  such  be 
discovered,  whether  in  the  abdomen  or  elsewhere,  they 
should  be  properly  dealt  with.  The  nose  especially 
should  be  carefully  examined,  and  if  there  beany  growth 
on  the  inferior  turbinate  bones,  surgical  treatment  will 
probably  cure  the  bronchial  complaint.  Dr.  Woakes^ 
in  his  work  on  '^  Nasal  Polypus,^'  has  clearly  ex- 
plained the  pathogeny  of  nasal  asthma,  and  has  cited 
several  cases  in  which  the  attacks  were  obviously 
dependent  on  the  presence  of  polypi  and  hypertrophy 
of  the  tissues  covering  the  inferior  and  middle  tur- 
binate bones.  He  recommends  the  gal vano- cautery 
and  chromic  acid.  When  bronchial  catarrh  is  pre- 
sent this  will  require  appropriate  remedies,  to  which 
may  be  added  the  inhalation  of  condensed  air.  For 
some  cases  of  this  kind  the  inhalation  of  oxygen  has 
been  found  serviceable.  I  have  made  trial  of  this  remedy 
in  several  cases  of  asthma,  and  have  had  every  reason  to 
be  satisfied  with  the  results.     An  inhaler  suitable  for 


TREATMENT  OF  ASTHMA.  469 

the  administration  of  nitrous  oxide  answers  the  purpose 
very  well;  it  should  be  used  about  an  hour-and-a-half 
after  a  meal,  and  either  in  the  morning  or  afternoon. 
Oxygen-water,  as  prepared  by  Messrs.  Brin,  is  also 
serviceable  in  asthma.  In  using  condensed  air  the 
patient  is  either  placed  in  a  pneumatic  cabinet  or  a 
portable  apparatus  is  used,  by  which  the  lungs  alone  are 
acted  upon.  It  has  been  recommended  that  the  patient 
should  inspire  compressed  and  expire  into  rarefied  air, 
and  apparatus  have  been  constructed  for  fulfilling  these 
purposes. 

Change  of  air  often  proves  most  efficacious  for 
asthmatic  subjects.  Dr.  Hyde  Salter  remarks  that 
residence  in  one  locality  will  often  radically  and  perma- 
nently cure  asthma  resisting  all  treatment  in  another 
locality.  The  localities  most  beneficial  for  the  great 
rriajority  of  cases  are  large,  populous,  and  smoky  cities, 
the  effect  depending  probably  on  the  air.  It  is  curious 
that  the  air  which  would  be  imagined  to  be  the  worst 
for  the  general  health  should  be  the  best  for  asthma, 
though  this  is  not  always  the  case.  When  the  patient's 
means  are  sufficient,  a  chan2;e  of  residence  from  time  to 
time  is  often  beneficial ;  thus,  during  the  summer,  tlie 
seaside  or  any  good  country  place  may  be  chosen;  in 


47©  TREATMENT  OF  ASTHMA. 

the  winter  the  south  of  France  or  the  Italian  coast, 
Madeira,  or  Egypt  may  prove  suitable.  The  condition 
of  the  bronchial  tubes  during  the  intervals  will  serve  in 
some  measure  as  a  guide  in  selecting  the  locality. 
Exercise  in  the  open  air,  and  warm,  tepid,  or  cold  baths 
are  all  likely  to  be  serviceable  according  to  circumstances. 

For  asthma  occurring  in  gouty  and  dyspeptic  sub- 
jects the  regulation  of  the  diet  and  mode  of  living  is 
all-important.  The  meals  must  be  small,  and  the  food 
easily  digestible.  The  patient  should  dine  at  two 
o'clock,  and  should  take  nothing  but  a  light  supper 
afterwards  ;  breakfast  should  be  the  chief  meal,  when 
meat,  eggs,  and  cocoa  may  be  taken  in  moderation. 
Stimulants  should  generally  be  avoided,  save  with 
meals  j  a  little  good  brandy  or  whisky,  well-diluted, 
may  then  be  allowed.  Distension  of  the.  stomach 
is  likely  to  prove  very  mischievous,  and  should  be  care- 
fully guarded  against.  For  plethoric  subjects  of  this 
kmd  a  course  of  treatment  at  Carlsbad,  Marienbad, 
Kissingen,  or  Homburg  is  likely  to  be  serviceable.  In 
all  cases  constipation  must  be  prevented  by  laxatives  or 
purgatives. 

Whenever  decided  periodicity  is  a  feature  of  the 
attacks  quinine  should  be  given    in    full    doses.     For 


TREA  TMENT  OF  A  STH3fA .  47 1 

anaemic  subjects  iron  is^  of  course,  indicated  ;  and  when- 
ever there  are  indications  of  nervous  depression  or  irrita- 
bility we  may  try  the  bromides^  oxide  of  silver^  or  arsenic. 
This  last  is  sometimes  very  efficacious,  and  is  always 
worthy  of  a  trial. 

In  some  forms  of  asthma,  notably  those  for  which 
no  special  cause  can  be  discovered^  iodide  of  potassium 
sometimes  proves  very  useful ;  it  should  be  given  in 
doses  of  gr.  v-x  three  times  a  day,  and  continued  for 
several  weeks.  A  few  drops  of  tincture  of  belladonna 
with  each  dose  would  not  interfere  with  its  efficacy,  and 
would  obviate  the  production  of  disagreeable  symptoms. 
It  has  also  been  recommended  that  the  tincture  of 
iodine  should  be  applied  to  the  sides  of  the  neck. 

Electricity  has,  of  course,  been  tried  in  cases  of 
asthma,  and  the  poles  are  recommended  to  be  applied 
in  various  positions.  Thus  they  can  be  placed  one  on 
each  side  of  the  thyroid  cartilage,  or  the  positive  pole 
applied  to  the  neck,  while  the  negative  is  placed 
between  the  larynx  and  the  sterno-mastoid  muscle. 
The  faradic  current  has  also  been  used,  the  electrodes 
being  placed  one  on  each  side,  either  below  the  angle  of 
the  jaw  or  on  a  line  with  the  thyroid  cartilage. 


CHAPTER     IV. 

HAY-ASTH  MA— HAY- FEVER. 


Hay-Asthma,  Questions  as  to  its  Nature — General  Description — 
First  recognized  by  Dr.  Bostock — Causes,  Predisposing  and 
Exciting — The  Pollen  of  Grasses,  and  of  various  Cereals — 
Dr.  Blackley's  Experiments — Symptoms — Affections  of  the 
Nose,  Eyes,  and  Throat — Cough  and  Difficulty  of  Breathing 
— Appearances  of  the  Affected  parts — Diagnosis — Treat- 
ment, Prophylactic  and  Curative. 

It  is  doubtful  whether^  in  the  present  state  of  our 
knowledge^  hay-asthma  can  fairly  be  classified  among 
functional  disorders.  It  is,  however,  very  closely  allied 
to  them;  and  although  the  theory  of  its  origination 
from  pollen  has  been  placed  on  a  very  sure  footing,  it  is 
by  no  means  certain  that  the  symptoms  cannot  be 
excited  by  other  causes. 

The  complaint,  variously  termed  hay-asthma,  hay- 
fever,  summer  catarrh,  and  June  cold,  is  a  catarrhal 
affection  implicating  the  conjunctivae,  mucous  membrane 
of  the  nose  and  of  the  entire  respiratory  tract ;  appear- 
ing in  the  early  summer  or  autumn  and  attacking  pre- 
disposed persons  in  the  same  manner  and  at  the  same 


NA  TURE  OF  RA  Y-A STRMA.  47.^ 

time  every  year.  Its  symptoms  resemble  those  of 
influenza;  the  implicated  mucous  membranes  being 
red,  swollen,  and  covered  with  increased  secretion ; 
sneezing,  fever,  cough,  and  attacks  similar  to  those  of 
asthma  make  up  the  clinical  features  of  the  disorder. 

It  is  interesting  to  find  that  an  English  physician. 
Dr.  Bostock,  was  the  first  to  recognize  and  describe 
this  complaint.  He  read  a  paper  on  a  "  Case  of  a 
Periodical  Affection  of  the  Eyes  and  Chest ''  before 
the  Medico-Chirurgical  Society  in  1819,  the  description 
given  being  that  of  his  own  case.  Some  years  after- 
wards, he  had  collected  nearly  30  additional  instances, 
And  he  advanced  the  theory  that  heat  was  the  real 
€ause  of  the  complaint,  in  opposition  to  the  popular 
idea  which  attributed  it  to  emanations  from  hay  and 
flowers.  Since  the  period  specified  the  number  of 
reported  cases  has  enormously  increased.  It  may  be 
that  the  disorder  is  more  common  now  than  it  was. 
in  former  times,  in  which  case,  its  increased  frequency 
is  analogous  to  that  of  many  nervous  disorders : 
possibly,  however,  increased  accuracy  of  diagnosis  may 
account  for  the  difference  in  the  number  of  cases. 
The  disorder  was  not  clearly  recognized  in  Germany 
till  1859. 


4  74  CA  US  US  OF  HA  Y-A  ST  MM  A . 


With  regard  to  the  causes  of  hay-asthma^  there  is 
still  much  diversity  of  opinion.  Ordinary  heat  and 
exposure  to  the  sun's  rays,  artificially  heated  air,  as 
that  of  greenhouses,  and  the  pollen  of  certain  grasses 
have  been  credited  with  the  causation  of  the  complaint. 
Before  examining  the  evidence  in  favour  of  the  claims 
of  any  of  these,  it  will  be  well  to  notice  the  persons 
who  are  especially  prone  to  be  attacked.  Statistics 
show  that  hay-asthma  is  more  prevalent  among  males 
than  females  ;  that  the  majority  of  the  patients  are  under 
40  years  of  age,  and  that  those  whose  pursuits  involve 
mental  toil  are  very  much  more  susceptible  than  labourers- 
of  all  kinds.  A  predisposition  to  attacks  is  often  trans- 
mitted from  one  generation  to  another  ;  a  nervous  tem- 
perament is  said  to  characterize  the  majority  of  the 
patients.  Some  authorities  state  that  decided  swelling 
of  the  nasal  mucous  membrane,  especially  of  that  cover- 
ing the  inferior  turbinate  bones,  is  an  antecedent  con- 
dition in  many  cases  of  hay-asthma. 

It  is  with  regard  to   the  exciting  causes  of  the  com- 
plaint that  many  different  views  have  been  and  still  are 
held.     Dr.  Bostock  considered  that  excessive  heat  was- 
the  chief  cause  ;  but   it  would   appear   that  somethhig: 
else  is  necessary.     Dryness  of  the  atmosphere  is  one 


CAUSES  OF  HAT-ASTSMA.  475 

requisite ;  moreover,  in  damp  and  cloudy  weather  the 
sufferers  always  feel  relieved.  The  dust  of  hay  has  long 
been  supposed  to  contain  the  exciting  causes  of  the 
affection  ;  patients  are  attacked  when  the  grass  becomes 
quite  ripe,  and  when  haymaking  is  going  on  the  cause 
becomes  still  more  active.  If  persons,  predisposed  to 
attack,  leave  the  country  district^  where  they  have 
suffered  for  many  years  previously,  and  spend  the 
summer  in  a  large  city  or  by  the  seaside,  they  remain 
free  from  the  symptoms.  The  pollen  of  the  grasses 
contained  in  hay  would  appear  to  be  the  agents  whereby 
the  attacks  are  excited  ;  and  a  similar  power  is  possessed 
by  wheat,  oats^  and  rye  in  bloom,  and  the  pollen  of 
many  sweet-scented  flowers.  Emanations  from  animals 
are  said  to  produce  a  similar  effect  on  some  persons. 
The  pollen  of  ragweed  (Ambrosia  artemisiaefolia)  is  a 
potent  cause  of  the  autumnal  variety  of  the  complaint 
frequently  seen  in  the  United  States. 

Dr.  Blackley,  of  Manchester,  has  performed  a  great 
many  experiments  which  show  that  the  symptoms  may 
be  induced  in  certain  individuals  by  applying  a  small 
quantity  of  the  pollen  of  various  plants  to  the  mucous 
membrane  of  the  nostrils.  He  also  detected  pollen  grains 
in  the   air,  and  determined  their   amount  at  different 


476  SYMPTOMS  OF  SAY- ASTHMA. 

altitudes,  by  attaching  to  kites  glass  slides  covered 
with  a  mixture  of  water_,  proof  spirit,  and  glycerine. 
Fully  95  per  cent,  of  the  pollen  belonged  to  the  Grami- 
naceae,  and  it  appeared  that  the  rise  and  progress  of 
the  complaint  corresponded  with  the  amount  of  pollen 
present  in  the  atmosphere.  The  chain  of  evidence 
connecting  hay-asthma  with  pollen  would,  therefore, 
seem  to  be  complete;  but  some  other  observers  still 
believe  that  the  complaint  may  be  produced  in  another 
way,  having  noticed  that  strong  light  or  sunshine  falling 
on  the  face  will  produce  a  paroxysm  of  sneezing  and 
that  the  other  symptoms  then  follow  in  quick  succes- 
sion. 

Symptoms.  In  many  cases  of  hay-asthma  the  effects 
rapidly  follow  the  operation  of  the  cause.  The  first 
symptoms  are  often  noticed  soon  after  a  walk  through  a 
hay-field  ;  but  sometimes  there  are  premonitory  sym- 
ptoms, such  as  a  feeling  of  malaise,  loss  of  appetite  and 
feverishness,  and  these  may  last  for  a  few  hours  or  even 
a  day  or  two.  The  symptoms  of  the  attack  closely 
resemble  those  of  coryza  ;  there  is  a  feeling  of  heat  and 
irritation  in  the  nose,  frequent  sneezing,  increased  secre- 
tion from  the  nasal  mucous  membrane,  and  obstruction 
■of  the  passages ;  swelling  of  the  membrane   covering 


S  YMPTOMS  OF  HA  Y-A  STEM  A .  47  j 

the  inferior  turbinate  bones  can  often  be  discovered  ;  taste 
and  smell  are  generally  much  impaired.  The  conjunc- 
tivae are  likewise  affected  ;  there  is  a  sensation  as  if  the 
eyes  were  full  of  dust,  the  lachrymal  secretion  is  in- 
creased;  there  is  intolerance  of  light^  hyperaemia,  and 
perhaps  oedema  of  the  lids.  The  mucous  membrane  of 
the  throat  often  participates ;  it  seems  to  be  hot,  dry 
and  rough,  and  there  is  much  uneasiness  or  even  diffi- 
culty in  swallowing ;  in  some  cases  the  throat-affection 
is  the  first  to  appear.  These  symptoms  may  constitute 
the  whole  of  the  complaint;  but  in  many  cases  laryn- 
geal and  bronchial  catarrh  is  superadded,  and  sometimes 
there  is  a  considerable  amount  of  fever,  pain  in  the  fore- 
head or  back  of  the  head,  or  a  feeling  of  pressure  and 
lowness  of  spirits.  Itching  of  the  skin  is  very  common, 
the  face,  back,  and  chest  being  mainly  affected  ;  an 
eczematous  eruption  is  sometimes  present.  Some 
patients  are  conscious  of  a  feeling  of  cold  in  the  nose, 
and  especially  at  the  tip  of  the  organ,  which  is  likewise 
cool  to  the  touch.  The  symptoms  occasionally  pass 
off  after  a  few  hours  or  in  a  day  or  two,  but  more  fre- 
quently they  continue  for  several  weeks.  Relapses  are 
common,  especially  if  the  patient  remain  in  the  neigh- 
bourhood of  hay-fields.  ^ 


478  SYMPTOMS  OF  HAY-ASTHMA. 

Symptoms  resembling  asthma  are  frequently  super- 
added, but  they  are  not  present  in  all  cases ;  they  seem 
to  result  from  extension  of  the  laryngeal  catarrh.  There 
is  at  first  a  frequent  and  dry  cough^  associated  with  a 
sensation  of  tickling  in  the  larynx^  and  the  expectora- 
tion of  a  little  transparent  mucus.  The  severity  of 
these  symptoms  is  much  influenced  by  the  state  of 
the  atmosphere ;  they  are  aggravated  during  hot  and 
dry  weather  and  considerably  relieved  after  a  rainfall. 
The  cough  is  often  spasmodic  in  character;  the  attacks 
occurring  in  paroxysms  of  considerable  duration  and 
causing  much  distress  to  the  patient.  It  is  stated  that 
small  crystals,  resembling  those  found  in  ordinary 
asthma,  have  been  discovered  in  the  expectoration. 

The  nasal  secretion,  which  is  often  very  copious, 
contains  vibriones  and  the  pollen  of  grasses,  either 
unchanged  or  swollen  and  flattened  ;  the  granules  some- 
times exhibit  spontaneous  movements,  and  occasionally 
form  small  chains. 

With  regard  to  the  appearance  of  the  affected  parts, 
the  mucous  membrane  of  the  nose,  throat,  and  larynx 
is  much  swollen,  hypersemic,  and  covered  with  secre- 
tion. Recovery  from  the  attacks  is,  of  course,  the 
general  rule ;  it  is  scarcely  possible  that  death  should 


TREATMENT  OF  HAT- ASTSMA.  479 

ever  be  caused  by  them,  exceptin  the  subjects  of  severe 
organic  disease.  Immunity  from  attacks  is  scarcely  if 
ever  attainable  by  those  who  have  already  suffered 
unless  the  patient  takes  up  his  abode  in  a  large  city. 

The  diagnosis  of  the  complaint  can  seldom  be  a 
matter  of  difficulty ;  the  local  symptoms  in  the  nostrils, 
eyes_,  and  throat,  and  the  attacks  of  sneezing,  and  of 
difficulty  of  breathing,  are  sufficient  to  indicate  the 
nature  of  the  case. 

Treatment.  The  only  way  to  avoid  attacks  is  to 
remove  to  a  locality,  e.g.,  a  large  town  or  seaside  place, 
in  which  the  complaint  is  unknown.  The  patient  must, 
of  course,  leave  the  country  before  the  hay  season  com- 
mences, and  remain  till  harvest  is  gathered  in.  For 
persons  who  are  obliged  to  stay  in  the  country.  Dr. 
Blackley  recommends  the  use  of  a  respirator  moistened 
with  a  weak  solution  of  carbolic  acid,  and  at  the  same 
time  the  wearing  of  spectacles  provided  with  closely- 
fitting  gauze  guards.  Something  may  be  done  to 
diminish  susceptibility  to  attacks  by  prescribing 
hygienic  measures  of  various  kinds,  such  as  cold  baths, 
liberal  diet,  with  tonics  and  stimulants.  When  a  patient 
has  been  exposed  to  the  causes  of  attacks  the  nose 
should  be  syringed  out  with  weak  solutions  of  quinine 


4.8o  TREA  TMENT  OF  HA  Y-A  STEM  A . 


or  carbolic  or  salicylic  acid,  and  the  same  remedies  mav 
be   freely    used  during    the  continuance  of  the    nasal, 
catarrh.      For  the   same    purpose  a  powder    has    been 
recommended   consisting  of  calomel  and  alum,  of  each 
9  parts,  hydrochlorate  of  morphine,    i   part ;  about  a 
grain  to  be  used  three  times  daily  as  a  snufF.     Such 
remedies  as  arsenic,  strychnine,  camphor,  and  bromide 
of  potassium  are  recommended  for  lessening  the  severity 
of  the  attacks,  and  small  doses  of  morphine  will  usually 
aid  in  relieving  the  patient's  distress.     For  the  same 
purpose  Sir  A.  Clark  recommends  the  local  application 
of  cocaine  (a  5  to  15  per  cent,  solution)  to  the  mucous- 
membrane  of  the  nose  and  back  of  the  pharyux,  on  a 
camel-hair  brush.     A  weaker  solution  may  also  be  used 
by  means  of  a   spray-apparatus.      In   cases   in  which 
the  mucous  membrane  of  the  inferior  turbinate  bones  is 
congested  and   hypertrophied  it    has  been    advised    ta 
remove  the  diseased  tissue  with  the  galvanic  cautery^ 
or  by  the  application  of  glacial  acetic  acid. 


SECTION  IV. 

FUNCTIONAL  DISORDERS    OF   THE  ORGANS 
OF  DIGESTION 


INTRODUCTORY  CHAPTER. 


Varieties  of  Functionai,  Disorders  now  to  be  Discussed — 
Affections  of  the  Stomach,  Intestines,  and  Liver — Their 
Peculiarities  and  Causes —Errors  in  Diet — Excess  of 
Nitrogenous  Food — Kidney  Affections  as  a  Secondary 
Result — Deficient  Supply  of  Nitrogenous  Materials — Bread 
as  a  Food — Influence  of  the  Tannin  of  Tea  on  Salivary 
Digestion — Effects  of  Improper  Food  —  Peculiarities  in 
Certain  Individuals — Effects  of  Nervous  Exhaustion — 
Spasm  of  the  Stomach  and  Intestines  —  Spasm  of  the 
QLsopHAGUS — Perversion  of  Gastric  and  Intestinal  Secre- 
tion— Effects  of  Nervous  Influence — Hepatic  and  Pan- 
creatic Secretion — Effects  of  Nervous  Influence  on  Intes- 
tinal Movements — Effects  of  Alterations  in  the  Blood 
Supply — Enumeration  of  the  Symptoms  of  Functional  Dis- 
orders OF  the  Stomach   and  Intestines. 

Functional  disorders  of  the  organs  of  digestion  offer 
a  wide  field  for  study.  Those  in  which  the  stomach, 
intestines,  and  liver  are  respectively  implicated  form  a 
large  and  important  category,  and  will  be  considered  in 
this  section.  In  connection  with  the  intestinal  tract 
we  meet  with  disorders  of  sensation,  motion,  and  secre- 

31 


482.       FUNCTIONAL  DISORDERS  OF  DIGESTION. 

tlon  J  functional  afiections  of  the  liver  are  evidenced  by 
perverted  sensations^  secretions^  and  metabolic  pro- 
cesses. Disorder  of  sensation  is  exhibited  in  such 
complaints  as  gastralgia,  enteralgia,  and  hepatalgia ; 
disorders  of  motion  in  colic,  constipation,  and  diarrhoea  ; 
while  disorder  of  gastric  and  biliary  secretion  is  shown 
in  many  forms  of  dyspepsia,  which  are  also  often 
accompanied  by  pain  and  disorder  of  movement  in  various 
parts  of  the  intestinal  tract.  These  functional  affections 
differ  in  one  important  respect  from  those  already  con- 
sidered, for  they  are  often  traceable  to  distinct  causes, 
<?.«•.,  in  the  case  of  the  stomach,  to  the  ingestion  of  food 
improper  in  quality,  or  excessive  in  amount.  Another 
marked  peculiarity  consists  in  the  fact  that  the  occur- 
rence of  one  condition  is  often  quickly  followed  by 
another;  thus  indigestion  is  frequently  associated  with 
gastralgia,  and  both  with  constipation  or  diarrhoea,  of 
which  the  indigestion  is  the  primary  cause.  Distur- 
bance of  one  function  is  speedily  followed  by  dis- 
order of  another,  so  close  is  the  mutual  interdependence 
of  the  various  organs  and  processes  of  which  they  are 

the  seats. 

The  causes  and  symptoms  of  the  functional  disorders 
of  the  alimentary   tract  will  be  minutely  discussed   in 


CAUSES  OF  BYSPEPSIA.  48.? 


succeeding  chapters ;  but  it  seems  advisable  to  make  a 
few  general  remarks  on  these  subjects  before  entering 
into  particulars.  With  regard  to  causation,  the  m- 
fluence  of  errors  in  diet  is  daily  becoming  more  and 
more  obvious,  and  nothing  is  more  certain  than  that 
the  majority  of  functional  disorders  of  the  stomach, 
^iver,  and  intestines  belong  to  the  class  of  preventable 
diseases.  If  we  take  as  an  example  any  one  of  the 
forms  of  indigestion  we  shall  almost  invariably  find  that 
it  is  traceable  to  errors  in  diet,  and  that  it  can  be 
relieved  or  cured  only  by  dealing  with  its  cause.  The 
same  holds  good  of  those  secondary  results  of  such 
errors  which  constantly  obtrude  themselves  in  the  form 
of  hepatic  derangements,  gouty  symptoms,  urinary 
deposits,  and  the  like. 

Among  the  well-to-do  classes  dyspepsia  is  by  far  the 
most  common  complaint,  and  its  causes  are  seldom  far 
to  seek;  excess  of  nitrogenous  food  is  the  most  potent 
of  these.  As  direct  consequences  of  such  excess,  the 
organs  engaged  in  preparing  and  assimilating  food  in 
order  that  it  may  serve  to  nourish  the  body,  become 
over-w^orked  and  eventually  break  down.  Moreover, 
when  too  much  nitrogenous  food  is  taken  some  of  it  is 
eliminated    without    .having    undergone   the   necessary 


484 .  CA  USES  OF  D  YSPFPSIA . 

changes,  and  acts  injuriously  upon  the  excretory  organs,^ 
and  especially  upon  the  kidneys  and  skin.  Albumin 
not  unfrequently  appears  in  the  urine  after  habits  of 
indulgence  in  excess  of  albuminous  food ;  some  portion 
of  the  excess  is^  doubtless,  got  rid  of  by  this  channel_,. 
but  at  the  risk  of  setting  up  destructive  changes  in  the 
kidneys.  In  my  work  on  Gout  I  have  endeavoured  to 
show  that  defective  assimilation  may  ultimately  result  in 
irritation  and  chronic  inflammation  of  the  kidney,  and 
may,  therefore^  be  regarded  as  one  cause  of  Bright^s 
disease.  Cutaneous  affections,  notably  eczema  and 
acne,  are  additional  consequences  of  malass'imilation, 
and  the  general  health  of  the  patient  sooner  or  later 
suffers,  as  shown  by  the  occurrence  of  such  symptoms 
as  lassitude,  incapacity  for  exertion,  disturbed  sleep,, 
headache,  and  impairment  of  the  mental  faculties.  If, 
as  is  often  the  case,  a  deficient  amount  of  exercise  be 
taken  at  the  same  time,  the  symptoms  are  more  marked 
and  more  rapid  in  their  onset. 

A  deficient  supply  of  nitrogenous  materials  is  a  far 
less  common  source  of  gastric  and  general  disorder; 
but  severe  suffering  is  occasionally  traceable  to  this 
cause.  Some  patients,  poor  women  especially,  live 
mainly  on  bread  and  tea,  and  meat  in  any  shape  forms 


EFFECTS  OF  TANNIN  ON  DIGESTION.  485 

a  very  small  part  of  their  diet.  Life  can,  of  course,  be 
supported  on  good  wheaten  bread,  which  (always  pro- 
vided that  whole  meal  be  used  for  its  manufacture) 
-contains  all  the  elements  necessary  for  nutrition, 
though  not  in  the  proper  proportions,  for  to  obtain  the 
300  grains  of  nitrogen  required  daily  by  the  system,  it 
would  be  necessary  to  eat  at  least  three  pounds  of  bread. 
This  would  involve  the  ingestion  of  nearly  double  the 
■quantity  of  carbon  required,  and  the  bulk  of  the  food 
would  give  rise  to  much  inconvenience.  In  the  patients 
referred  to  the  amount  of  bread  taken  is  much  less 
than  this,  and  as  such  persons  almost  invariably  choose 
white  bread,  the  quantity  of  nitrogen  is  altogether 
insufficient  for  the  wants  of  the  economy.  There  is, 
however,  another  drawback  connected  with  the  diet 
referred  to,  viz.,  that  tea  is  a  powerful  retarder  of 
salivary  digestion,  and  it  owes  this  property  to  the 
large  proportion  of  tannin  that  it  contains.  Hence,  a 
diet  composed  of  tea  and  bread  is  a  fertile  cause  of 
dyspepsia  and  gastralgia,  for  much  of  the  starchy 
matter  remains  for  some  time  in  the  stomach,  and 
passes  out  of  it  in  an  undigested  condition.  Peptic 
digestion  is  retarded  by  malt  liquors  as  well  as  by  tea 
and  coffee. 


486      IMPROPER  FOOD  AS  A  CAUSE  OF  DISORDER. 

The  effects  of  improper  food  may  be  described  in  a 
few  words.  In  this  category  are  included  substances, 
either  naturally  indigestible,  or  imperfectly  prepared. 
Disorder  of  the  di2:estive  organs  is  often  traceable  to 
this  cause.  It  is  only  necessary  to  mention  unripe 
fruits,  the  rinds  and  seeds  of  fruits,  and  the  stalks  of 
leaves ;  very  few  uncooked  vegetables  are  thoroughly 
digested.  The  symptoms  which  matters  of  this  kind 
induce  are  of  common  occurrence,  and  are  generally 
recognized.  Eating  unripe  fruit_,  or  even  ripe  fruit 
in  excess,  is  apt  to  be  followed  by  colic  and 
diarrhoea,  and  some  persons  are  very  susceptible  in  this 
respect.  There  are  also  many  curious  idiosyncrasies  in 
reference  to  the  effects  of  articles  of  food,  some  of 
which,  harmless  to  most  people,  act  as  poisons  upon  a 
few  individuals.  Thus  we  find  that  some  persons 
cannot  eat  eggs  in  any  form  without  very  severe  suffer- 
ing; others,  again,  are  affected  by  shell-fish;  intense 
gastric  irritation,  conjunctivitis,  or  severe  urticaria 
being  the  invariable  penalties.  The  effect  of  cold  drinks 
in  retarding  digestion  has  long  been  recognized,  but  the 
warnings  of  experience  are  apt  to  be  neglected.  Iced 
drinks,  taken  with  or  soon  after  meals,  are  powerful 
causes  of  indigestion.  ■ 


VARIOUS  SYMPTOMS  OF  GASTRIC  DISORDER.    487 

In  order  that  the  food  should  be  thoroughly  mixed 
with  the  secretions  of  the  stomach,  and  converted  into 
chyme^  the  movements  of  the  organ  must  be  perfectly 
carried  on,  and  in  various  disordered  conditions  these 
movements  are  either  exaggerated  or  impaired,  or 
associated  with  various  kinds  of  painful  sensations. 
Among  the  causes  which  impair  the  activity  of  the 
movements,  may  be  mentioned  nervous  exhaustion  in 
general,  and  especially  when  due  to  excessive  mental 
strain.  Verv  decided  symptoms,  referable  to  gastric 
paralysis,  are  not  unfrequentiy  seen  in  persons  who 
after  a  heavy  meal,  perhaps  towards  the  close  of  the 
day,  at  once  occupy  themselves  with  severe  mental 
work.  The  nervous  energy  necessary  for  digestion  is 
diverted  into  other  channels,  and  the  processes  in  the 
stomach  come  to  a  standstill,  or  are  very  imperfectly 
performed.  The  same  result  sometimes  follows  violent 
and  protracted  bodily  exercise  taken  under  similar 
circumstances. 

In  another  class  of  cases  the  disorder  takes  the  form 
of  spasm,  and  this  is  often  set  up  by  the  presence  of 
articles  of  food  ;  the  spasm  is  paroxysmal,  and  always 
accompanied  by  severe  pain.  It  must  not  be  forgotten 
that  symptoms   of  a  like  character  are  sometimes  con- 


488  SFASM  OF  THE  (ESOPHAGUS. 

nected  with  spinal  disorders,  and  notably  with  loco- 
motor ataxy.  When  the  intestines  are  affected  the 
condition  is  known  as  colic;  it  may  be  due  to  articles 
of  food,  to  lesions  of  the  intestines,  to  lead  poisoning, 
or  to  strangulated  hernia.  The  last-named  cause 
should  never  be  forgotten  in  all  cases  of  abdominal 
pain,  and  especially  in  women,  in  whom  a  small 
femoral  hernia  may  easily  escape  observation,  and, 
though  the  cause  of  severe  pain,  perhaps  in  the  um- 
bilicus or  upper  part  of  the  abdomen,  may  itself  be 
almost  painless. 

In  connection  with  the  subject  of  spasm  of  the 
stomach  and  intestines,  it  is  worth  while  to  refer 
briefly  to  a  similar  condition  of  the  oesophagus.  This 
is  of  rare  occurrence,  but  it  may  easily  be  mistaken  for 
gastric  disorder,  and  for  organic  stricture  of  the  oeso- 
phagus itself.  The  contraction  takes  place  at  or  near 
the  pharyngeal  end  of  the  tube ;  there  is  a  sore  spot  or 
downright  stoppage  with  return  of  food  :  in  some  cases 
swallowing  is  painful  and  performed  irregularly.  When 
spasm  exists  the  regurgitation  is  almost  immediate;  the 
food  is  flung  back  and  not  retained  for  40  or  50 
seconds,  as  occurs  in  organic  stricture  of  the  oeso- 
phagus, and  liquids   generally  are   more   resented    than 


PERVERSION  OF  SECRETION.  489 

solids.  The  history  also  presents  certain  charac- 
teristics ;  there  is  generally  dyspepsia  of  a  gouty 
•character;  the  urine  is  abnormallv  acid,  and  the 
stomach  and  intestines  are  liable  to  tympanitic  disten- 
sion. Dr.  Brinton^  who  has  described  several  of  these 
•cases  {Lancet,  Vol.  i.^  1866)  explains  them  as  follows: 
the  muscular  contractions  of  the  intestinal  tube  are 
influenced  by  irritations  extrinsic  to  itself.  Acidity 
•causes  spasm  of  the  muscular  wallsj  and  the  end  of  the 
pharynx  is  especiallv  liable  to  be  affected^  because  the 
voluntary  part  of  swallowing  is  there  translated  into  an 
involuntary  act. 

Perversion  of  secretion  is  another  and  very  important 
factor  in  the  production  of  functional  disorders  of  the 
alimentary  tract;  and  when  we  reflect  upon  the  number 
and  variety  of  the  secretions  poured  into  the  intestinal 
canal^  the  uses  for  which  thev  are  adapted,  and  the 
innumerable  kinds  of  food  which  are  subjected  to  their 
action,  we  cannot  but  marvel  at  the  comparative 
infrequency  of  signs  of  irregular  action.  Secretion  is 
well  known  to  be  under  the  influence  of  the  nervous 
system ;  the  salivary  secretion  is  the  most  prominent 
instance  of  this  character,  and  we  may  easily  believe 
that  the  gastric,   intestinal,  and   hepatic  secretions  are 


490        INFLUENCE  OF  NERVES  ON  SECRETION. 

similarly  influenced.  We  know  that  the  state  of  the 
tongue  and  throat  is  often  aflfected  by  nervous  excite- 
ment j  that  swallowing  is  sometimes  impossible,  even  \w 
the  absence  of  organic  disease,  and  there  is  every  reason 
to  suppose  that  the  stomach  may  be  subject  to  in- 
fluences of  this  character.  There  is  no  nerve  passing- 
to  the  stomachy  whose  stimulation  causes  a  secretion 
of  gastric  juice,  as  the  chorda  tympani  does  in  the 
submaxillary  gland  ;  but  certain  experiments  point  to- 
the  existence  of  local  secretory  centres  in  the  stomach,, 
and  there  is  evidence  to  show  that  there  is  some  connec- 
tion between  the  central  nervous  system  and  the  gastric- 
glands.  In  a  case  of  gastric  fistula  it  was  found  that 
even  the  si(>"ht  or  smell  of  food  caused  secretion 
(Landois).  With  regard  to  the  effect  of  nervous 
influence  upon  the  secretion  of  bile,  very  little  appears, 
to  be  known,  and  the  results  of  experiments  are  con- 
tradictory. It  has,  however,  been  proved  that  dilatation 
of  the  abdominal  vessels,  such  as  follows  section  of  the 
splanchnics  or  of  the  spinal  cord,  is  followed  by  an 
increased  flow  of  bile,  while  irritation  of  the  cord  has 
opposite  effects  on  the  vessels  and  secretion  respectively. 
Still  less  is  known  as  to  the  effect  of  nervous  in- 
fluence  upon  the  pancreatic   secretion.     The   latter  is 


INFLUENCE  OF  NERVES  ON  SECRETION.       491 

excited  bv  direct  stimulation  oF  the  (jland  itself,  and  bv 
irritating  portions  of  the  medulla  oblongata;  while  it  is 
lessened  or  suppressed  by  stimulation  of  the  central 
extremity  of  the  vagus,  and  by  irritating  other  sensory 
nerves,  as  the  crural  and  sciatic.  How  far  the  nervous 
system  is  concerned  in  connection  with  intestinal 
secretion  is  a  matter  of  complete  uncertainty.  On  the 
other  hand  the  influence  of  nerves  on  the  intestinal 
movements  is  very  considerable,  and  has,  to  some 
extent  at  least,  been  ascertained.  The  intestinal  canal 
contains  an  automatic  motor  centre  w^ithin  its  walls, 
between  the  lonsfitudinal  and  circular  muscular  fibres. 
When  this  plexus  is  unafl^ected  by  any  stimulus  the 
movements  of  the  intestines  cease;  when  food  passes 
from  the  stomach  into  the  bowels  peristaltic  contrac- 
tions of  a  reflex  nature  at  once  be2:in.  The  effect  of 
the  food  is  heightened  by  the  condition  of  the  blood- 
vessels ;  when  these  latter  are  turg^id  with  blood  the 
irritability  of  the  nervo-muscular  apparatus  is  consider- 
ably increased,  so  that  slight  stimuli  produce  a  com- 
paratively strong  effect.  Venous  congestion  causes 
increased  peristalsis ;  and  the  active  movements  of  the 
intestines,  which  often  occur  as  the  result  of  mental 
excitement,  are  due  to  derangements  of  the  circulation. 


492       INFLUENCE   OF  NERVES  ON  INTESTINES. 

The  continuous  application  of  strong  stimuli  causes 
complete  paralysis  of  the  intestine,  as  is  seen  in  acute 
peritonitis  and  enteritis. 

The  movements  of  the  small  intestines  are  increased 
by  stimulating  the  vagus;  the  splanchnic,  on  the  other 
hand_,  is  an  inhibitory  nerve^  at  least  to  some  extent, 
but  when  the  blood  in  the  capillaries  becomes  venous, 
stimulation  of  this  nerve  increases  the  movements. 
The  splanchnics  are  the  vaso-motor  nerves  of  the 
abdominal  viscera;  when  they  are  irritated  all  the 
intestinal  vessels,  which  contain  muscular  fibres  in 
their  walls,  contract;  when  they  are  divided  the  vessels 
dilate,  and  anaemia  consequently  results  in  the  other 
parts  of  the  body.  .  The  splanchnic  is  also  the  sensory 
nerve  of  the  intestine,  and  as  such,  under  certain 
circumstances,  it  may  give  rise  to  extremely  painful 
sensations. 

The  effects  of  alterations  in  the  blood-supply  have 
been  incidentally  alluded  to  in  preceding  paragraphs  ; 
but  changes  in  the  quality  of  the  blood  also  play  a 
certain  part  in  the  causation  of  disorders  of  the  abdo- 
minal organs.  Blood  in  which  some  of  the  normal 
constituents  are  defective  will  not  yield  proper  secretions, 
and  thus  the  food  will  be  liable  to  be  imperfectly  acted 


FUNCTIOXAL  DISORDERS  OF  DIGESTION.       493 

upon.  In  this  way  a  vicious  circle  readily  becomes 
established^  inasmuch  as  the  secretions  themselves  are 
dependent  on  the  pabulum  which  the  blood  receives 
through  the  instrumentality  of  the  assimilating  organs. 
In  like  manner^  when  the  blood  is  overloaded  with 
impurities^  the  secretions  derived  from  it  cannot  fail  to 
be  abnormal  in  many  respects.    • 

With  regard  to  the  symptoms  of  functional  disorders 
of  the  stomach  and  intestines^  these  will  be  fully 
described  and  their  significance  pointed  out  in  succeeding"^ 
chapters.  They  may  be  briefly  recapitulated  and  sum- 
marized as  those  which  are  referable  to  the  affected 
organ,  and  those  which  make  themselves  felt  in  other 
parts.  In  the  former  category  will  be  included  such 
symptoms  as  derangements  of  appetite,  perverted  sensa- 
tions, flatulence  and  eructation,  nausea  and  vomiting, 
constipation  and  diarrhoea.  A  numerous  category  of 
symptoms  are  connected  with  other  organs.  The 
kidneys  have  been  already  alluded  to.  They  are  often 
the  first  to  suffer,  and  cutaneous  affections  are  frequentlv 
superadded.  The  action  of  the  heart  is  generally  inter- 
fered with;  palpitation  and  intermittency  are  conmion 
symptoms  of  dyspepsia.  Even  the  lungs  occasionally 
become  affected ;    dyspnoea  and  attacks  of  asthma  are 


494      FUNCTIONAL  DISORDERS  OF  DIGESTION. 

sometimes  traeeable  to  the  state  of  the  stomach.  The 
nervous  system  especially  suffers  in  another  class 
of  cases^  the  symptoms  exhibited  being  more  marked  in 
this  portion  of  the  organism  than  in  the  abdominal 
viscera  themselves.  Headache,  vertigo,  depression  of 
spirits,  irritability,  incapacity  for  mental  exertion, 
sleeplessness,  hypochondriasis,  and  many  forms  of 
neuralgia  often  owe  their  origin  to  functional  disorders 
of  the  stomach,  liver,  or  intestines.  Nutrition  also  is 
affected  in  not  a  few  of  these  cases,  the  patients  be- 
coming thin,  ansemic,  and  debilitated,  and  these  sym- 
ptoms are  sometimes  so  prominent  as  to  give  rise  to  the 
suspicion  of  serious  organic  disease.  It  only  remains 
to  add  that  patients  who  have  long  suffered  from  the 
effects  of  these  functional  disorders  are  especially  prone 
to  fall  victims  to  attacks  of  infectious  diseases. 
Tuberculosis,  for  example,  is  often  preceded  by  indi- 
cations of  gastric  and  intestinal  disorder.  No  reference 
has  been  made  to  the  symptoms  of  hepatic  functional 
disorders;  they  are  of  an  important  character,  and 
require  to  be  discussed  in  a  separate  chapter. 


CHAPTER     II. 

DYSPEPSIA— INDIGESTION. 


Functions  of  Stomach  and  Intestines — Mechanical  Actions  and 
Chemical  Changes  Therein — Meaning  of  Term  Dyspepsia — 
Relations  with  Catarrh — The  Vascular  Apparatus  of  the 
Stomach — Strong  and  Weak  Digestions — Causes  of  Dyspepsia 
■ — Faults  Connected  with  the  Diet — Use  of  Fluids,  Alcohol, 
Tobacco— Positions  of  the  Body,  Exertion  after  Meals, 
Nervous  Excitement,  Disorders  of  Stomach — Anatomical 
Changes  in  Catarrh — Symptoms  of  Acute  Dyspepsia — Chronic 
Forms — Influence  on  the  Mental  Condition — Results  of  Re- 
peated Ai  tacks — ^ilATTERS  Ejected  from  the  Stomach — For- 
mation OF  Organic  Acids — Increase  of  Salivary  Secretion — 
Pyrosis— Constipation — Diarrhcea — The  Urine  and  Skin — 
General  Condition  of  the  Patient — Cardiac  Symptoms — 
Vertigj  —  Course  and  Duration  —  Diagnosis  —  Prognosis — 
Treatment  of  Acute  Attacks — Rest — An  Emetic — Alkalies — 
Laxatives — Treatment  of  Chronic  Forms — Attention  to  Diet 
— The  State  of  the  Teeth — Articles  of  Diet  Suitable — 
Fluids — Milk  Diet — Treatment  of  Constipation,  Laxatives 
Suitable — Aloes,  Cascara,  Salines — Stronger  Purgatives — 
Hygienic  Measures  as  Change  of  Air,  Exercise,  Baths — 
Medicines  such  as  Acids,  Alkalies,  Bismuth,  and  Charcoal — 
Treatment  of  Irritative  Dyspepsia — Arsenic,  Ipecacuanha — 
Question  of  Health-Resorts. 

The  stomach  and  the  intestinal  canal  have  a  doable 
task  to  perform.  They  have  to  act  mechanically  upon 
the  materials  which  are  introduced   into  them,  and  they 


496  DEFINITION  OF  DYSPEPSIA. 

are  the  seat  of  not  a  few  chemical  processes,  set  up  by 
the  secretions  of  glands  which  form  an  important  part 
of  their  structure,  or  whose  excretory  ducts  open  into 
their  cavities.  The  chemical  changes  are  intimately 
connected  with  the  mechanical  action  of  the  parts  con- 
cerned, for  they  are  altered  in  various  ways  when  the 
food  introduced  into  any  portion  of  the  digestive  canal 
is  detained  for  too  long  or  for  too  short  a  time.  Patho- 
logical disorder  of  the  movements  of  the  intestines  is, 
therefore,  generally  associated  with  disorder  of  diges- 
tion, and  when  the  chemical  processes  are  at  fault  the 
imperfectly-prepared  materials  influence  the  mechanical, 
action  of  the  viscera. 

As  a  general  rule,  functional  alterations  involve  a 
large  portion  of  the  digestive  tube;  they  remain  con- 
fined to  one  spot  only  when  the  irritation  is  comparatively 
slight.  Disorders  of  the  stomach  and  bowels  are,  there- 
fore, frequently  associated ;  it  rarely  happens  that  the 
one  is  affected  without  the  other  being;  more  or  less 
implicated. 

The  term  dyspepsia  is  used  to  describe  functional 
disorders  in  which  the  stomach  is  principally  involved, 
and  is  contrasted  with  those  changes  designated  by  the 
word  catarrh  which  are  of  an  inflammatory  nature,  and 


DYSPEPSIA  AND  GASTRIC  CATARRH.  497 

affect  the  surface,  or  at  least  the  mucous  membrane, 
principally.  No  such  sharp  line  of  demarcation  can, 
however_,  be  drawn  between  the  two  conditions,  for 
experience  teaches  us  that  the  difference  is  only  one  of 
degree,  and  that  many  of  the  transitional  stages  are 
not  to  be  separated  from  each  other.  Long- continued 
indigestion  invariably  leads  to  catarrh,  just  as  the  latter, 
sooner  or  later,  involves  the  former. 

The  relations  between  these  two  processes  may  be 
easily  traced.  If  undigested  materials  remain  in  the 
stomach,  they  undergo  fermentative  and  putrefactive 
changes,  with,  as  a  result,  the  formation  of  substances, 
e,g.,  butyric  and  acetic  acids,  which  are  especially 
qualified  to  provoke  inflammation.  A  similar  result 
may  follow  the  operation  of  a  very  different  cause. 
When  the  stomach  contains  food,  mental  excitement 
may  check  the  secretion  of  gastric  juice  and  the  move- 
ments of  the  organ,  and  may  thus  produce  catarrh. 
This,  however,  is  a  less  common  cause.  Individual 
peculiarities,  dependent  upon  a  variety  of  circumstances, 
tend  to  increase  or  lessen  the  susceptibility  of  the 
gastric  mucous  membrane.  The  epithelium  of  the 
stomach  and  intestines  and  the  number  and  activity 
of  the  glands  vary  in  different  subjects,  as  we  find  to 

3^ 


498  WEAK  AND  STRONG  DIGESTIONS. 

be  the  case  with  correspondmg  portions  of  the  cutaneous 
integument. 

As  contributing  to  the  production  of  functional  dis- 
order, we  must  not  forget  to  mention  the  irritability  of 
the  vascular  apparatus  of  the  stomach,  and  the  manner 
in  which  it  responds  to  the  influence  of  the  nervous 
system.  Other  elements  in  the  calculation  are  the 
power  of  resistance  possessed  by  the  cellular  structures 
and  the  tissues  which  they  compose  ;  and,  lastly, 
the  quantity  and  condition  of  the  muscular  coat  of 
the  stomach  and  intestines.  It  is  only  by  assuming 
the  existence  of  differences  in  the  powers  of  these 
parts  that  we  are  able  to  explain  how  it  is  that 
one  individual  can,  without  apparent  difficulty,  eat 
and  digest  substances  which  would  upset  another 
person  for  hours  or  days.  The  terms  ''  weak  "  and 
"  strong  ^'  applied  to  stomachs  may  not  be  very 
scientificj  but  they  serve  to  express  differences  which 
undoubtedly  exist.  It  is  easy  to  explain  the  fre- 
.quent  association  of  disorders  of  the  stomach  with 
those  of  the  intestines.  When  any  irritating  ingesta 
are  not  rejected  by  the  stomach  they  pass  into  the 
intestine,  where  they  excite  increased  peristaltic  action, 
and   possibly   diarrhoea.      If,   however,  they  remain   in 


CAUSES  OF  DYSPEPSIA.  499 

the  intestine,  and  are  not  rendered  innocuous  by  the 
various  secretions  which  there  become  blended  with 
theiTij  they  will  at  all  events  cause  irritation,  and 
possibly  inflammation  of  the  bowels. 

Irresfularities  and  disorders  of  disrestion  are  due  to  a 
great  variety  of  causes,  some  of  them  being  connected 
with  the  mechanical  movements  of  the  parts,  and 
others  with  the  necessary  chemical  processes.  It  is 
important  to  bear  both  factors  in  mind  when  treating  a 
case  of  indigestion. 

The  causes  of  indigestion  may  be  grouped  under  the 
following  heads  : — 

T.  Food  of  an  unsuitable  character  and  imperfectly 
prepared. — The  object  of  the  cook's  art  is  to  render 
food  pleasant  to  the  palate  and  fit  for  digestion.  If 
the  first  object  be  accomplished  the  second  is  apt  to  be 
regarded  as  comparatively  immaterial.  If  the  palate  be 
pleased,  and  fashionable  tastes  be  gratified,  other  con- 
siderations are  neglected.  It  must  be  admitted  that 
some  amount  of  improvement  has  taken  place  of  late 
years  in  England ;  we  have  learnt  that  a  reduction  in 
the  quantity  of  nitrogenous  food  is  not  only  practicable, 
but  very  beneficial  in.  a  large  majority  of  cases.  There 
is,   however,    much    still    that   is    faulty;    too     much 


S'oo  CAUSES  OF  DY8PI:PSIA. 

authority  is  still  left  to  the  palate,  with  little  considera- 
tion for  the  powers  of  the  stomach. 

2.  Improper  intervals  between  meals. — Two  faults 
may  be  included  in  this  category,  the  one  being  much 
more  common  than  the  other^  Indigestion  is  some- 
times caused  by  eating  too  frequently ;  the  stomach  is 
never  allowed  to  be  at  rest;  but  a  far  more  frequent 
source  of  mischief  is  the  long  interval  that  busy  men 
especially  are  apt  to  allow  between  meals.  This  is 
certainly  the  case  with  reference  to  the  modern  dinner 
and  the  hour  at  which  it  is  taken.  Many  a  man  works 
hard  all  day,  takes  little,  if  anything,  at  luncheon,  and 
does  not  sit  down  to  dinner  till  eight  or  half-past  eight. 
His  nervous  system  is  too  much  exhausted  to  be  able  to 
supply  the  force  requisite  for  digestion. 

3.  Insufficient  division  and  preparation  of  the  food 
while  in  the  mouth. — This  is  a  very  common  cause  of 
indigestion  ;  persons  whose  thoughts  are  fully  occupied, 
either  with  work  or  play,  are  apt  to  think  that  the  time 
spent  in  eating  is  wasted,  and  meals  are  got  through  as 
quickly  as  possible.  It  is  true  that  common  propriety 
necessitates  the  use  of  a  knife,  but  this  implement  is 
employed  as  seldom  as  possible,  the  teeth  do  little  or 
nothing,  and  the  aid  of  saliva   is  almost  refused  :   the 


CAUSES  OF  JDTSPIEPSIA.  501 

food  is  swallowed^  but  not  eaten.  Immoderate  eaters 
often  sin  against  themselves  in  the  manner  just 
described;  some  of  them,  indeed_,  never  seem  to  use 
the  muscles  of  mastication.  Persons  with  defective  teeth 
unwittingly  offend  in  a  similar  manner.  There  is  another 
source  of  mischief  connected  with  bolting  the  food  ;  it 
is  apt  to  reach  the  stomach  while  still  at  a  very  high 
temperature,  and  to  disorder  the  secretory  action  of  the 
glands  by  the  irritation  it  creates. 

4.  The  drinking  of  a  large  quantity  of  fluid  at  a  low 
temperature  is  a  potent  cause  of  indigestion.  Too  much 
stress  cannot  be  laid  upon  this  fact ;  persons  are  far  too 
apt,  especially  during  hot  weather,  to  take  immoderate 
quantities  of  iced  fluids  during  meals.  The  symptoms, 
in  some  cases,  quickly  follow  their  cause  ;  the  cold 
applied  to  the  lining  membrane  of  the  stomach  converts 
its  hyperaemic  state  to  one  of  anaemia,  and  cannot  fail 
to  disorder  the  muscular  movements  of  the  organ.  It 
is  true  that  the  feeling  of  exhaustion,  and  likewise  of 
hunger,  is  allayed  by  the  cold  fluid,  but  the  stomach  has 
to  pay  the  penalty. 

5.  The  use  of  strong  alcoholic  fluids,  especially 
when  these  are  taken  upon  an  empty  stomach.-^ — .The 
operation  of  this   cause  is   universally   recognized ;  the 


502  CAUSjES  OF  DTSPUPSIA. 

worst  use  to  which  stimulants  can  be  put  is  to  take 
them  between  meals  j  they  irritate  the  stomach,  set  up 
hypersemia  in  portions  of  its  mucous  membrane,  and 
cause  increased  secretion  of  mucus,  which  acts  as  a 
ferment.  They  are,  moreover,  speedily  absorbed  and 
conveyed  to  the  liver,  whose  function  they  disturb,  and 
in  whose  tissues  they  produce  serious  alterations. 
Besides  causing  local  changes,  alcohol,  after  acting  as  a 
stimulus,  depresses  the  nervous  system  and  thus 
interferes  with  digestion,  and  the  fermentation  which 
some  alcoholic  liquors  undergo  in  the  stomach  is  a 
source  of  further  mischief. 

6.  The  use  of  strong  tobacco  comes  next  in  order  as 
a  cause  of  indigestion,  the  mischief  being  proportionate 
to  the  strength  and  other  peculiarities  of  the  narcotic. 
The  dryness  in  the  mouth  and  throat,  doubtless, 
extends  to  the  stomach,  and  if  the  saliva  be  ejected 
starchy  articles  of  food   will  be  insufficiently  prepared 

for  digestion. 

7.  Constrained  positions  of  the  body  and  tightly 
fitting  clothes  may  contribute  to  the  causation  of  dys- 
pepsia by  interfering  with  themovements  of  the  stomach 
and  bowels.  Tight  lacing  among  women  comes  under 
this  head,  and  among  the  lower  classes,   the  stooping 


CAUSES  OF  DYSPEPSIA.  503 


posture  adopted  by  tailors  and  shoemakers^  and  also  by 
some  clerks^  is  a  fertile  source  of  indigestion. 

8.  Exertion  after  a  full  meal.  For  digestion  to  be 
properly  accomplished  the  organs  at  work  must  receive 
a  sufficient  supply  of  blood.  This  process  is^  how- 
ever, obstructed  if  the  activity  of  other  portions  of  the 
body  simultaneously  claims  an  increased  supply  of  that 
fluid.  Thus  it  is  that  active  mental  or  bodily  exertion  im- 
mediately after  meals  checks  digestion_,  for  it  causes  the 
blood  to  be  diverted  into  other  channels.  On  the  other 
hand,  deep  sleep  is  almost  always  prejudicial,  for  it 
lessens  the  excitability  of  the  nervous  system  in  general 
and  retards  the  circulation.  There  is,  however^  some 
diflference  in  opinion  with  regard  to  the  desirability  of  an 
after-dinner  nap.  Those  who  advocate  it  cite  the 
example  of  animals,  but  these  gorge  themselves  with 
food,  and  are  heavy  and  drowsy  in  consequence.  A 
short  rest  is,  however,  different  from  lethargic  sleep, 
and  often  appears  to  do  good.  Severe  brain-work  after 
dinner  is  certainly  mischievous,  and  should  always  be 
forbidden  :  the  interval  between  a  late  meal  and  bed- 
time should  be  devoted  to  recreation  and  amusement. 

9.  Nervous  excitement  is  another  cause  of  indiges- 
tion.    It  is  well   known   that  during  such  a  condition 


504  CAUSES  OF  DYSPEPSIA. 

the  want  of  food  is  scarcely  felt,  and  that  when  a  meal  is 
taken  discomfort  is  very  apt  to  be  created.  Nervous 
exhaustion,  already  alluded  to  in  a  previous  paragraph, 
is  another  cause  of  this  character.  A  man  may  feel 
terribly  in  want  of  food  after  a  hard  day^s  work,  but  he 
has  little  or  no  power  of  digestion  left.  If,  as  is  often 
the  case  under  such  circumstances,  he  eats  freely  and 
rapidly  when  opportunity  occurs,  one  form  of  dis- 
comfort is  speedily  exchanged  for  another. 

10.  The  last  cause  of  indigestion  which  requires 
notice  is  that  which  is-  connected  with  diseases  ot 
various  kinds.  Disorders  of  the  stomach  and  bowels, 
febrile  affections,  and  severe  diseases  of  all  kinds  are 
accompanied  by  more  or  less  decided  symptoms  of 
indigestion,  due  to  the  fact  that  the  stomach  is  in- 
sufficiently supplied  with  blood,  and  also  to  the  distur- 
bances in  the  nervous  system. 

Acute  dyspepsia,  uncomplicated  by  organic  disease, 
leaves  no  traces  discoverable  after  death.  We  know, 
from  observations  on  animals  and  on  persons  with 
gastric  fistula,  the  changes  which  the  mucous  mem- 
brane undergoes  during  digestion,  but  these  disappear 
after  death.  The  indications  of  gastric  catarrh  are 
often  visible,  and  take  the  form  of  marked  hyperaemia. 


SYMPTOMS  OF  DYSPEPSIA.  505 

sometimes  associated  with  extravasation  of  blood  in 
points  or  patches.  The  mucous  membrane  is  swollen^ 
covered  with  a  tenacious  adherent  layer  of  mucus  and 
epithelial  cells  of  various  kinds ;  sometimes  the  deeper 
seated  vessels  show  signs  of  inflammation.  The 
evidences  of  chronic  dyspepsia  or  catarrh  are  often 
seen  in  the  dead  body ;  they  consist  mainly  of  atrophy 
of  the  mucous  membrane,  and  of  the  submucous  con- 
nective tissue.  Thickening  of  the  connective  tissue^ 
with  deposits  of  pigment  and  destruction  of  the  glands, 
and  either  hypertrophy  or  atrophy  of  the  muscular 
fibres  are  frequently  discoverable. 

The  symptoms  of  an  acute  attack  of  dyspepsia  are 
of  a  marked  character_,  but  they  vary  with  the  cause 
and  with  the  individual.  In  the  most  common  form 
there  is  nausea  and  eructations^  with  increased  secretion 
of  saliva,  and  followed  by  retching  and  vomiting,  by 
means  of  which  the  contents  of  the  stomach  are  sooner 
or  later  discharged.  Sometimes  a  portion  of  the  fluid 
matters  contained  in  the  duodenum  is  also  ejected  ;  the 
greenish  colour  and  bitter  taste  indicate  the  presence  of 
bile.  If  the  matters  vomited  have  been  but  a  short 
time  in  the  stomach,  the  other  symptoms  will  soon 
pass  off";  disorder  of  the  intestines  will  either  be  very 


5o6  SYMPTOMS  OF  DYSPEPSIA, 

slight  or  altogether  absent.  On  the  other  hand^  under 
opposite  conditions,  diarrhoea  is  very  apt  to  be  set  up. 
Persons  differ  very  considerably  in  their  proneness  to 
vomit ;  as  a  general  rule^  other  things  being  equal,  an 
irritable  stomach  affords  a  better  protection  against  the 
bad  effects  of  ingested  materials  than  one  which  is  less 
sensitive.  When  the  vomiting  is  over,  but  little  dis- 
comfort may  remain  beyond  a  transient  feeling  of 
exhaustion.  When,  however,  severe  irritation  has 
been  set  up  the  suffering  may  be  proportionately  great. 
There  is,  for  example,  great  pain  in  the  stomach,  with 
intense  and  persistent  nausea,  and  even  after  the  organ 
is  empty  the  patient  may  be  greatly  distressed  by  efforts 
at  retching,  during  which  a  little  mucus  or  bile  maybe 
ejected.  Diarrhoea  is  likely  to  set  in,  accompanied  by 
colicky  pains,  and  the  whole  of  the  abdomen  is  tender 
on  pressure.  The  tongue  is  swollen  and  thickly 
coated,  there  is  severe  prostration  and  headache;  food 
of  all  kinds  is  regarded  with  loathing,  but  water  is 
often  taken  ravenously  only  to  be  rejected  immediately. 
There  is  no  elevation  of  temperature;  the  pulse,  if 
altered  at  all,  is  less  frequent  than  usual.  These 
symptoms  last  for  a  variable  period,  sometimes  for 
several  hours,  and  they  may  subside  from  time  to  time, 
and  again  recur. 


5  YMF  TOMS  OF  JD  YSPEPSIA .  507 

Chronic  forms  of  indigestion  are  much  more  common 
than  the  acute  type;  they  make  up,  indeed,  no  small 
proportion  of  the  ills  to  which  flesh  is  heir.  Whatever 
be  the  character  of  the  discomforts,  their  development 
is  a  more  or  less  chronic  process.  In  very  many  cases 
the  first  evidence  of  disorder  is  denoted  by  the  patient's 
becoming  aware  of  the  fact  that  .he  possesses  a  stomach. 
He  is  apt  to  find  this  out  after  substantial,  though  by 
no  means  necessarily  immoderate  meals.  The  dis- 
covery is  associated  with  the  desire  to  loosen  the 
clothes  round  the  lower  part  of  the  chest,  inasmuch  as 
the  pressure  seems  to  be  the  cause  of  the  discomfort. 
In  all  but  the  slightest  attacks,  further  symptoms  are 
superadded,  and  take  the  form  of  eructations,  first  of 
gaseous  matters,  and  then  of  particles  of  food,  the  taste 
of  which  is  perceptible  some  hours  after  it  has  been 
swallowed,  a  feeling  of  heat  in  the  throat  and  stomach, 
with  increase  of  saliva.  These  may  be  the  only 
symptoms,  and  they  may  recur  more  or  less  frequently 
during  long  periods.  Retching  and  vomiting  are, 
however,  often  superadded.  The  bowels,  too,  are  apt 
to  become  irregular  in  their  action  ;  sometimes  there  is 
constipation,  and  sometimes  diarrhoea,  especially  after 
eating.  All  these  symptoms  may  go  on  for  years 
without  apparent  influence  upon  the  patient's  health. 


So8  SYMPTOMS  OF  DTSPFFSIA. 


Unless  much  pain  be  likewise  present,  they  are  often 
unheeded.  A  careful  person  will  notice  that  the 
symptoms  are  liable  to  be  provoked  by  sundry  articles  of 
food,  and  he  will  abstain  from  them^  or  take  them 
only  in  great  moderation.  It  is  only  a  select  few, 
however,  who  can  exercise  such  restraint,  more  espe- 
cially if  the  food  to  be  avoided  is  of  a  highly  palatable 
character.  If  the  warnings  given  by  the  stomach  be 
neglected  a  variety  of  ill  consequences  sooner  or  later 
make  themselves  felt.  The  mental  condition  shows 
signs  of  change;  application  to  study  becomes  difficult, 
ideas  soon  get  confused  and  do  not  flow  readily,  the 
temper  becomes  irritable,  the  patient  feels  either 
depressed  or  excited,  and  takes  pessimistic  views  of 
things  in  general.  All  the^e  symptoms  are  aggravated 
by  constipation,  which  so  often  accompanies  dyspepsia, 
and  in  not  a  few  cases  a  condition  of  melancholia  or 
hypochondriasis  supervenes. 

In  chronic  cases,  in  which,  owing  to  their  frequent 
repetition,  the  symptoms  have  reached  a  high  degree  of 
severity,  the  condition  of  the  patient  is  far  more  serious. 
There  is  loss  of  appetite,  which  may  so  far  be  described 
as  complete,  inasmuch  as  whatever  is  taken  has  to  be 
forced    down,   and  these   attempts    are  followed   by   a 


SYMPTOMS  OF  DYSPEPSIA.  509 

feeling  of  weight  and  pain,  which  may  amount  to 
cardialgia.  A  burning  sensation  at  the  back  of  the 
throatj  attended  by  retching_,  eructations  of  acrid 
matters,  vomiting,  and  constipation,  alternating  with 
diarrhoea,  and  such  like  symptoms,  are  more  or  less 
troublesome  in  different  cases.  The  abdomen  is  at  first 
generally  prominent,  but  later  on  it  is  apt  to  be 
retracted.  The  passage  of  flatus  from  the  lower  bowel 
is  often  a  prominent  symptom.  There  are  disagreeable 
tastes  in  the  mouth,  and  the  breath  has  an  unpleasant, 
and  sometimes  even  putrid  odour,  which  is  especially 
marked  whenever  the  mouth  and  teeth  are  not  kept 
clean.  The  emaciation  which  sets  in  is  a  measure  of 
the  serious  disorder  of  nutrition. 

Certain  of  the  symptoms  require  to  be  considered 
somewhat  more  in  detail.  An  examination  of  the  matters 
ejected  from  the  stomach  demonstrates  the  presence  of 
acetic  and  butyric  acids,  which  are  the  products  of  the 
fermentation  of  amylaceous  substances.  Carbonic  acid 
is  sometimes  present  in  large  quantities,  and  is  derived 
from  the  same  source.  The  products  of  the  decomposi- 
tion of  albuminous  substances  can  be  detected  in  some 
cases,  and  among  these  sulphuretted  hydrogen  is  the 
most   common  ;   it   may   become  absorbed  and    cause 


5IO  SYMPTOMS  OF  DYSPEPSIA. 

symptoms  of  poisoning.  The  idea  has  for  a  long  time 
been  prevalent  that  the  symptoms  of  mental  depres- 
sion^ so  common  in  cases  of  dyspepsia,  are  attributable 
to  the  absorption  of  the  products  of  putrefactive 
decomposition,  and  this  notion  is  supported  by  the 
knowledge  recently  obtained  of  the  properties  of  the 
ptomaines. 

The  formation  of  the  organic  acids  in  the  stomach 
prevents  the  preparation  and  solution  of  albuminous 
matters,  and  the  acids,  moreover,  act  as  direct  irritants. 
In  dyspeptic  cases  the  quantity  of  hydrochloric  acid  in 
the  gastric  juice  is  generally  much  diminished,  and  the 
conversion  of  albumen  into  peptone  is  therefore  limited. 
The  pepsine,  also,  is  less  than  the  normal  amount,  but 
is  generally  sufficient  for  the  digestion  of  albumen, 
though  the  process  may  be  a  very  tedious  one.  The 
accumulation  of  peptones  leads  to  a  similar  result,  and 
the  delay  thus  caused  is  further  increased  by  the  in- 
ordinate secretion  of  mucus  and  the  less  frequent  and 
^  active  movements  of  the  stomach,  which  retard  absorp- 
tion, and  the  passage  of  its  contents  into  the  duodenum. 
Under  such  circumstances^  and  bearing  in  mind  the 
fact  that  excitants  of  putrefaction  readily  gain  access  to 
the  stomach  with  the  food  that  is  swallowed,  it  is  no 
wonder  that  this  process  so  often  becomes  developed. 


P  YE  OS  IS  AS  A  SYMPTOM  OF  DYSPEPSIA.       511 

The  salivary  secretion  is  often  much  changed  in  cases 
of  dyspepsia.     It  is  generally  increased  as   a  result  of 
reflex  action  set  up  by  the  abnormally  acid  state  of  the 
stomach.       If    swallowed    it    may    produce    vomiting, 
especially  if,  as  often  happens,  much  air  be  mixed  with 
it.     The  term  pyrosis  is  applied  to   describe  a  profuse 
flow    of   saliva    and    consequent    discharge    from    the 
mouth  of  a  clear  fluid,  often  occurring  in  the  course  of 
acid  dyspepsia.     The  discharge  is  attended  with  more 
or  less  cramp  in  the  stomach,  and  both  are  paroxysmal, 
\     but  there  is  no  ejection  of  the  contents  of  the  stomach. 
Sir  W.  Roberts,   who  has  carefully  studied   this  sym- 
ptom, states  that  the   '^  gush    of  saliva  is    something 
tremendous,  often  greater  than  incessant    swallowing 
efforts  can  dispose  of,  and  the  surplus  flows  out  abun- 
dantly from  the  mouth.   ...     A  paroxysm  of  this  kind 
only  occurs  during  the  presence  of  surplus  acid   in  the 
stomach.-"     In  gastric  catarrh  occurring  in  drunkards, 
the  quantity   of  saliva  swallowed  during  the   night   is 
sometimes  so  great  that  its  presence  can  be  detected  by 
chemical  tests  in  the  matters  vomited  in  the  morning. 

With  regard  to  the  other  abdominal  symptoms  the 
constipation  is  due  in  some  measure  to  the  fact  that  an 
abnormally  small  quantity  of  food  passes  into  the 
intestines,   and  the  result  is   aided  by  the   diminished 


S 1 2  S  YMPTOMS  OF  B  YSPHPSIA . 


energy  of  the  peristaltic  action.  The  food  remains  for 
lengthened  periods  in  the  large  intestine^  and  loses 
much  of  its  watery  constituents.  The  attacks  of 
diarrhoea  are  the  consequence  of  catarrh  of  the  colon, 
which  in  its  turn  is  produced  by  the  presence  of  faecal 
masses.  The  attacks  may,  however,  be  due  to  irritation 
of  the  small  intestines,  the  result  of  the  passage  into 
them  of  imperfectly  digested  matters  from  the  stomach. 
The  abdominal  tenderness  which  often  accompanies 
dyspepsia  may  be  due  to  irritation  of  the  peritoneum, 
caused  by  distension  of  the  intestines,  or  possibly  to 
the  accumulation  of  the  products  of  retrogressive  meta- 
morphosis. The  circulation  of  the  blood  through  the 
abdominal  organs  is  more  or  less  retarded  ;  the  sensi- 
tiveness to  pressure  extends  over  the  whole  abdomen, 
or  at  least  over  large  portions  of  it,  and  the  pain  is 
everywhere  of  the  same  character,  and  cannot  be 
localized  in  any  one  organ.  Spontaneous  pain  in  the 
back  and  loins  is  also  a  common  symptom. 

The  condition  of  the  urine  varies  in  different  cases, 
and  in  the  same  patient  at  different  times.  The  secre- 
tion often  contains  a  disproportionate  quantity  of 
urates,  which  are  deposited  on  standing,  and  oxalate  of 
lime  and  deposits  of  the  amorphous  phosphate  of  lime 


.<?  YMPTOMS  OF  D  YSPEPSIA .  513 

are  not  unfrequent.  In  cases  of  gouty  dyspepsia  the 
urine  is  often  scanty  and  high-coloured,  and  contains  3. 
minute  quantity  of  albumen,  the  presence  of  which  is 
due  to  derangement  of  the  functions  of  the  liver  and 
consequent  defective  metamorphosis  of  nutritive  ma- 
terials. Disorders  of  the  skin  are  also  common  in 
cases  of  dyspepsia,  and  take  the  form  of  acne,  eczema, 
erythema,  or  urticaria.  In  gouty  cases  eczema  is 
frequently  present. 

The  influence  of  indigestion  upon  the  general  condi- 
tion of  the  patient  is  often  very  marked.     The  principal 
agents  concerned  in  producing  the  effects,  are  the  pro- 
ducts  of  decomposition  set  free  in  the  intestines,  but 
other    causes    are    often    at    work.       The    effects,    for 
example,    of    anaemia   are    frequently    traceable,    and 
besides    these    the    results    of   irritation  of   the  vao-us 
and  sympathetic  nerves  which  supply  the  stomach  and 
intestines  are  seen  in  the  psychical  disorders  so  common 
in   dyspepsia.     Among  these  may  be   mentioned  that 
inactive  condition    of  the  brain  w^hich  shows  itself  in 
sluggishness    of   the    flow    of    ideas,    and    difficulty    in 
forming  conclusions  and  followino;  them  out,  and  this 
may  well  depend  upon  a  deficient  supply  of  blood  to 
the  nerve-centres,  or  upon  alterations  in  the  composition 

33 


5'i4  SYMPTOMS   OF  DYSPEPSIA. 

of  that  fluid.  The  rapid  variations  in  the  mental  state 
of  the  patient  may  be  thus  accounted  for.  More  or  less 
pronounced  sleeplessness  is  a  very  common  accompani- 
ment of  indigestion,  and  is  due  either  to  distension  of 
the  stomach  or  to  the  presence  of  imperfectly  assimilated 
matters  in  the  blood,  or  possibly  to  both  causes. 

The  last  set  of  symptoms  requiring  to  be  noticed  in 
any  detail  are  those  which  refer  to  the  organs  of  circu- 
lation. The  action  of  the  heart  is  often  much  modified 
in  cases  of  dyspepsia.  As  a  general  rule  the  pulse  is  less 
frequent  than  natural,  but  this  condition  is  often  rudely 
interrupted  by  attacks  of  palpitation,  attended  by  a 
feeling  of  distress  and  violent  pain  shooting  down  into 
the  left  arm.  These  symptoms  may  be  so  severe  as 
closely  to  resemble  angina  pectoris,  attacks  of  which 
are,  as  is  well  known,  often  provoked  by  the  condition 
of  the  stomach.  Vertigo  from  gastric  causes  is  another 
troublesome  symptom  in  not  a  few  dyspeptic  patients. 
The  symptom  has  been  fully  discussed  in  a  preceding 
chapter;  it  is  only  necessary  to  say  here  that  it  is 
often  associated  with  disorder  of  the  heart's  action  and 
cerebral  anaemia.  The  sensation  in  these  cases  is 
generally  described  as  though  surrounding  objects  were 
in  motion  around  the  patient,  or  as  though  the  ground 


SYMPTOMS  OF  JDTSFUFSIA.  515 

were  coming  up  to  meet  him.  This  form  of  vertigo  is 
very  common,  but  it  must  never  be  forgotten  that  some 
auditory  lesion  may  exist,  and  that  the  state  of  the 
stomach  may  serve  only  to  excite  an  attack. 

The  special  condition  known  as  nerv^ous  dyspepsia 
will  be  discussed  in  a  separate  chapter^  as  it  presents 
several  features  which  distinguish  it  from  the  more 
ordinary  forms  of  the  complaint. 

The  course  and  duration  of  the  symptoms  of  indiges- 
tion depend  for  the  most  part  on  their  causation  and 
severity.  In  acute  forms  the  symptoms  rapidly  subside 
under  proper  treatment,  and  may  not  recur  if  suitable 
rules  for  living  be  enjoined  and  obeyed.  On  the  other 
hand,  some  chronic  forms  of  dyspepsia  constitute  the 
most  tedious  and  obstinate  complaints  which  the  phy- 
sician has  to  treat,  but,  as  in  all  similar  cases,  very  much 
depends  upon  the  individuality  of  the  patient,  the  circum- 
stances by  which  he  is  surrounded,  and  his  willingness 
and  power  to  act  upon  medical  advice. 

The  diagnosis  that  dyspepsia  exists  is  an  easy  task; 
but  the  difficulty  is  to  determine  whether  the  symptoms 
are  purely  functional,  or  whether  they  depend  upon 
some  organic  lesion.  A  catarrhal  state  of  the  gastric 
mucous  membrane  is  rarely  absent  in  severe  cases,  and 


5'i6  PROGNOSIS  OF  DYSPEPSIA. 

is  evidenced  by  the  quantity  of  mucus  which  is  dis- 
charged from  time  to  time  by  vomiting.  With  regard 
to  serious  lesions  affecting  the  stomachy  the  physician 
has  to  think  especially  of  malignant  disease  and  of 
ulceration.  In  the  former^  a  tumour  v^ill  be  sooner  or 
later  perceptible  in  the  neighbourhood  of  the  pylorus, 
and  the  matters  vomited  will  at  some  time  or  other  con- 
tain blood.  The  absence  of  free  hydrochloric  acid  from 
the  gastric  juice  is  indicative  of  cancer.  If  no  tumour 
be  discoverable^  such  other  symptoms  as  cachexia,  swell- 
ing of  the  supraclavicular  lymphatic  glands  on  the  left 
side,  and  the  age  of  the  patient  will  point  towards 
malignant  disease.  In  cases  of  gastric  ulcer^  the 
patients  are  usually  anaemic  or  chlorotic;  the  pain  is 
often  very  violent  and  referred  to  one  spot,  and  it  is 
almost  certain  to  be  induced  by  taking  food.  Haemor- 
rhage is  also  a  common  symptom,  the  blood  at 
times  appearing  suddenly  and  in  considerable  quan- 
tities. 

The  prognosis  in  cases  of  dyspepsia  depends,  of 
course,  upon  the  diagnosis.  It  is  favourable  in  acute 
cases  provided  that  no  organic  disease  can  be  detected. 
In  chronic  cases  we  must  take  into  consideration  the 
general    condition    of  the  patient,  the  severity  of  the 


TREATMENT  OF  DYSPEPSIA.  517 


symptoms,,  and  the  other  points  referred  to  as  influenc- 
mg  the  course  and  duration  of  the  complaint.  In  old 
people  in  whom  there  is  reason  to  suspect  atrophy  of 
the  mucous  membrane  of  the  stornach,  the  prognosis 
cannot  be  otherwise  than  unfavourable. 

The  treatment  of  acute  attacks  of  dyspepsia  is  easy 
and  simple ;  the  irritated  organ  must  be  placed  at  rest. 
For  this  purpose  food  of  all  kinds  should  be  interdicted 
until  the  symptoms  have  completely  subsided ;  a  little 
water  or  soda-water  may  be  sipped  from  time  to  time, 
the  patient  keeping  perfectly  quiet^  and  in  the  recumbent 
position.  A  mustard  plaister  applied  to  the  epigastrium 
will  not  only  relieve  pain,  but  will  have  a  soothing  eiFect 
upon  the  irritated  organ.  If  there  be  ineffectual  attempts 
at  vomiting,  it  will  be  well  to  administer  an  emetic,  and 
this  treatment  .is  especially  suitable  for  cases  in  which 
the  attack  is  obviously  due  to  some  marked  error  in  diet. 
A  scruple  of  ipecacuanha  in  half  a  tumbler  of  tepid 
water,  or  a  teaspoonful  of  mustard  similarly  adminis- 
tered, will  be  found  suitable  for  these  cases  ;  and  tepid 
water  alone  is  sufficient  for  some  patients.  If  the  efforts 
at  vomiting  continue  after  the  stomach  has  been  emptied, 
we  may  allow  the  patient  to  suck  ice,  or  administer  a 
little  effervescing  water  containing  five  or  six  minims  of 


5i8  tbjeatm:ent  of  dysfupsia. 

tincture  of  opium  ;  the  mustard  plaister  is   especially 
suitable  for  such  symptoms. 

If  there  be   excessive  secretion  of  gastric  juice,  and 
the  eructation  of  a  highly  acid  fluid,  half-a-teaspoonful 
of  sodium  bicarbonate  dissolved  in  a  little  water  will 
afford  relief.     Should  diarrhoea  set  in,  it  is  well  not  to 
attempt  to  check  it  unless  it  persist  after  the  bowels 
have  been  thoroughly  emptied  of  faeces  ;  in  that  case  we 
may  give  a  few  drops   of  laudanum  with  chalk  mixture 
and  aromatics.     Warmth  to  the  abdomen  is  generally 
grateful  and  can  be  supplied  by  means  of  poultices,  or 
an  india-rubber  bag.     If  there  be  constipation,  a  mild 
but  eflScacious  laxative  should  be  given  after  the  gastric 
symptoms    have    subsided  ;    from    gr.    J   to    gr.    ij    of 
calomel,  followed  by  a  little  solution  of  magnesia,  may 
prove    sufficient,  and    a   draught,   containing   rhubarb, 
magnesia,  and  soda,  may  be   used  to  produce  a  more 
decided  effect.      After  the  symptoms  have  passed  -off  a 
warm  bath,  followed  by  rest  in  bed,  will  help  to  remove 
any  feelings  of  discomfort.     The  patient  must  be  very 
cautious  in  returning  to   ordinary  diet;  light  and  easily 
digestible  articles  should  be  taken  in  moderation,  and 
excesses  of  all  kinds  should   be  avoided.     The  patient 
should  likewise  beware  of  exposure  to  cold  and  damp. 


ATTENTION  TO  DIET.  519 

In  the  treatment  of  chronic  indigestion  the  condition 
of  the  stomach  must,  of  course,  occupy  the  first  place 
in  the  consideration,  but  the  functions  of  the  body 
generally  must  on  no  account  be  neglected.  Each 
case  has  to  be  studied  separately,  and  even  though  it 
may  prove  impossible  to  discover  the  primary  cause  of 
the  symptoms,  yet  it  will  generally  be  feasible  after 
careful  examination  to  detect  errors  in  diet  and  living 
which  contribute  to  perpetuate  the  disorder.  Bearing 
in  mind  the  causes  noticed  in  preceding  paragraphs,  and 
after  making  himself  acquainted  with  the  symptoms,  the 
physician  should  inquire  as  to  the  food,  the  time  for 
meals,  the  manner  in  which  these  are  taken,  the  fluids 
used,  and  the  other  points  already  referred  to.  It  often 
happens  that  something  faulty  can  be  detected  referable 
to  all  these  headings,  and  it  is,  therefore,  desirable  to 
lay  down  rules  for  the  patient's  guidance  both  as  to  the 
quality  and  quantity  of  the  food.  To  quote  what  I  have 
elsewhere  said  on  this  subject,  "I  have,  for  some  time 
past,  been  in  the  habit  of  supplying  my  patients  with 
printed  diet  rules.  I  keep  at  hand  a  set  of  forms  on 
which  the  hours  for  meals  and  the  articles  that  may  be 
taken,  and  those  that  must  be  avoided  are  clearly  speci- 
fied.    As  a  matter  of  course   modifications  by  way  of 


520  TREATMENT  OF  DYSPEPSIA. 

addition  or  subtraction  are  sometimes  required,  and 
spaces  are  therefore  left  for  additions.  I  attach  the 
greatest  importance  to  these  diet  rules ;  a  patient  is  far 
more  likely  to  obey  instructions  contained  in  a  printed 
form  than  verbal  directions,  however  emphatically 
expressed/' 

Before  considering  the  question  of  diet,  the  physician 
'should  always  inquire  into  the  state  of  the  teeth,  and 
this  precaution  is  especially  necessary  in  treating  middle- 
aged  and  elderly  patients.  Defective  teeth  are  a  fertile 
cause  of  indigestion,  the  remedy  for  which,  under  such 
circumstances,  is  to  be  found  in  the  skill  of  the  dentist. 
Having  attended  to  this  particular,  we  must  next  pre- 
scribe the  diet,  and  it  is  often  necessary  to  remind  the 
patient  that  it  is  a  bad  habit  to  take  only  one  good  meal 
per  diem,  and  little  or  no  nourishment  at  the  other  meal 
hours.  On  the  other  hand,  the  daily  amount  of  food 
should  be  divided  into  three  approximately  equal  portions, 
and  taken  at  intervals  of  four  or  five  hours.  The  last  meal 
should  be  eaten  two  or  three  hours  before  bed-time. 
The  work  thrown  upon  the  stomach  is  thus  fairly  distri- 
buted ;  the  organ  is  never  overburdened,  and  it  has  its 
periods  of  rest.  When  small  quantities  of  food  are  fre- 
quently taken  the  stomach  is  constantly  being  excited 


ATTJSNTION  TO  DIET.  521 

to  increased  activity^  and  is  never  quite  emptied  ;  fatigue 
of  its  muscular  coat  and  exhaustion  of  the  nervous 
energy  which  presides  over  secretion  must  sooner  or 
later  occur.  In  regulating  the  diet  for  chronic  cases 
we  get  but  little  aid  from  the  experience  of  the  patients, 
for  they  have  often  forgotten  what  the  sensation  of 
perfect  digestion  really  amounts  to.  The  object  to  be 
compassed  is  to  restore  this  sensation,  and  we  endeavour 
to  do  this  by  supplying  food  in  sufficient  quantity  to 
nourish  the  system,  while  it  makes  as  slight  a  call  as 
possible  upon  the  powers  of  the  stomach,  and  does  not 
by  its  tastefulness  invite  to  excess. 

With  regard  to  the  articles  of  diet  from  which  a 
selection  must  be  made,  mutton,  beef,  game,  chicken, 
fish,  and  eggs  make  up  the  list  of  animal  substances ; 
green  vegetables,  stale  bread,  and  a  small  quantity  of 
butter  may  generally  be  allowed.  The  mutton  and  beef 
should  never  be  overdone ;  the  eggs,  too,  should  be 
lightly  cooked ;  the  other  articles  are  dressed  in  the 
usual  way.  They  are  all  easy  of  digestion  and  are  not 
likely  to  set  up  acid  fermentation  in  the  stomach.  The 
patients  should  always  be  warned  against  the  ill  effects 
of  rapid  eating.  Fluids  should  be  taken  sparingly  at 
meal-times,  and  for  most  dyspeptics  two  or  three  glasses 


522  TEEATMEKT  OF  DYSPEPSIA. 

of  sound  claret  with  some  alkaline  effervescing  water 
will  be  found  suitable.  If  the  patient  prefer  it,  an 
ounce  of  good  brandy  or  whisky,  well  diluted,,  may 
replace  the  claret.  For  many  patients  hot  water  (with 
or  without  a  little  sugar)  may  be  mixed  with  the  claret 
with  advantage ;  iced  drinks  are  to  be  scrupulously 
avoided.  The  stomach  should  never  be  distended  ; 
"many  dyspeptics  should  on  this  account  avoid  soup; 
others  may  take  a  few  spoonfuls  with  advantage.  Pastry 
of  all  kinds  must,  of  course,  be  forbidden ;  milk  puddings 
are  generally  allowable.  Most  dyspeptic  patients  have 
to  be  very  careful  in  the  use  of  bread;  for  some,  indeed, 
it  is  better  to  prescribe  toast  and  plain  biscuits.  When- 
ever there  is  much  flatulence,  all  kinds  of  starchy  food, 
e.g.,  bread,  potatoes,  rice,  etc.,  must  be  avoided  ;  and 
when  bread  is  again  allowed  it  should  have  been  baked 
at  least  twenty-four  hours  previously.  Aerated  bread  is 
better  than  the  ordinary  kind,  which  is  too  often  sour 
and  indigestible.  For  the  morning  meal,  cocoa  made 
from  the  nibs  is  preferable  to  either  tea  or  coffee ;  the 
latter,  indeed,  must  be  forbidden  to  most  dyspeptic 
patients.  Tea  may  sometimes  be  allowed,  but  it  must 
be  taken  in  strict  moderation  and  with  plenty  of  milk. 
The  highly  astringent  Indian  teas  are  not  advisable  for 
these  patients. 


MILK  FOE  DYSPEPTIC  PATIENTS.  523 

In  dyspeptic  patients  who  are  at  the  same  time  the 
subjects  of  anaemia,  the  loss  of  appetite  which  is  often 
noticeable  is  sometimes  due  to  the  fatigue  which  the  act 
of  eating  produces ;  and  under  such  circumstances  after 
a  few  mouthfuls  the  patient  is  disinclined  to  make  any 
further  attempts.  The  difficulty  should  be  overcome  by 
administering  fluid  or  semi-fluid  nutriment,  which 
makes  little  demands  upon  the  muscles  of  mastication. 
Milk  thickened  with  amylaceous  materials  and  pepto- 
nized milk  are  very  suitable  for  these  patients,  and  in 
extreme  cases  peptonized  nutrient  enemata  or  suppo- 
sitories may  be  used.  With  regard  to  a  milk-diet  in 
general,  we  know  that  this  fluid  contains  everything 
that  is  necessary  for  nutrition^  and  that  life  can  be  main- 
tained for  almost  indefinite  periods  upon  it  alone.  But  in 
order  that  the  necessary  quantity  of  nutriment  should  be 
introduced,  a  large  volume  of  milk,  perhaps  five  or  seven 
pints,  must  be  supplied.  In  an  ordinary  stomach,  how- 
ever, there  is  great  risk  of  undue  distension  if  so  large 
a  quantity  be  taken,  and  this  condition  cannot  but 
impede  the  movements  of  the  organ.  Moreover,  the 
casein  is  apt  to  form  hard  lumps,  for  the  solution  of 
which  much  time  may  be  required.  These  large  quan- 
tities of  milk  are  therefore  badly  borne  by  many  patients, 
and  some  modifications  are  rendered  necessarv.     Three 


524  TRIIATMENT  OF  DYSPEPSIA. 

or  four  pints  may  be  tolerated  without  difficulty;  but 
the  amount  of  nutriment  therein  contained  is  insufficient 
for  the  daily  wants,  and  some  addition  is  requisite. 
Several  slices  of  well-toasted  bread,  or  a  corresponding 
number  of  biscuits,  may  be  soaked  in  the  milk,  and 
such  diet  may  be  persevered  with  for  several  days,  often 
with  great  advantage  to  the  patient,  provided,  of  course, 
that  he  is  kept  at  rest  at  the  same  time.  The  transition 
to  a  more  r^utritious  diet  should  be  very  gradually  made ; 
some  peptonized  food,  either  Savory  and  Moore's  or 
Benger's,  may  first  be  tried,  and  these  can  be  followed, 
if  the  patient  likes  them,  by  lightly  boiled  eggs.  After 
a  few  days  sweetbread  and  boiled  fowl  may  be  allowed, 
and  these  may  be  replaced  by  boiled  or  roast  mutton, 
roast  fowl,  and  roast  beef.  The  directions  given  in  pre- 
ceding paragraphs  with  regard  to  the  meal -times  and 
the  avoidance  of  rapidity  should,  of  course,  be  carefully 
attended  to. 

The  cure  of  dyspepsia  is  not  to  be  regarded  as  com- 
plete until  the  patient  has  regained  the  sensations  which 
a  healthy  stomach  experiences  after  food  is  taken. 
When  this  stage  has  been  reached,  and  provided  that 
the  patient  is  capable  of  exercising  a  due  amount  of  self- 
control,  he  may  be  allowed  some  latitude  in  the  choice 


EEMEDIES  FOR  CONSTIPATION.  525 

of  viands.  If  any  difficulties  recur  he  should  at  once 
go  back  for  a  day  or  two  to  his  former  restricted  diet. 
The  condition  of  the  bowels  always  requires  attention, 
and  when  constipation  is  present,  means  must  be 
adopted  for  its  relief.  Laxatives  are  often  required,  but 
these  should  be  given  with  the  view  of  restoring  the 
natural  action  of  the  bowels.  This  latter  should  be 
further  encouraged  by  a  visit  to  the  closet  at  a  regular 
hour  daily,  even  if  there  be  no  desire  to  defaecate. 
Drastic  purgatives  are  always  to  be  avoided ;  their  use 
would  only  exaggerate  the  evils  they  are  intended  to 
remove.  The  extract  of  aloes  is  one  of  the  best  remedies 
for  the  cases  under  consideration,  and  it  may  be  advan- 
tageously combined  with  belladonna,  quinine,  and 
henbane,  or  with  the  dried  sulphate  of  iron  in  lieu  of 
the  quinine.  The  following  prescription  will  be  found 
useful  in  many  cases : — R  Extract.  Aloes  Socot.  gr. 
j-jssj  Quininae  Sulphat.  gr.  j  (vel  Ferri  Sulphat. 
Exsiccat.  gr.  J);  Extract.  Belladonnae  gr.  ^;  Extract. 
Hyoscyami  gr.  j  ;  misce,  fiat  pil  j.  This  pill  may  be 
taken  daily,  or  as  required,  before  or  after  the 
midday  meal,  or  at  bedtime,  and  when  regularity  of 
the  bowels  is  attained  the  aloes  should  be  diminished 
in    quantity.      For   some    patients    the    new    laxative. 


526  TRJEATMENT  OF  BYSPFPSIA. 

cascara  sagrada,  acts  satisfactorily.  It  is  best  given  in 
the  form  of  the  liquid  extract,  of  which  nxxv-xxv  may  be 
taken  night  and  morning,  the  dose  being  regulated 
according  to  circumstances.  Messrs.  Squire  have 
introduced  a  palatable  and  convenient  elixir  of  cascara, 
of  which  the  dose  is  a  tablespoonful.  Saline  purgatives 
are  suitable  for  some  cases  of  dyspepsia,  and  especially 
for  gouty  subjects  of  full  habit.  The  salts  may  be  very 
conveniently  administered  in  some  one  or  other  of  the 
natural  mineral  waters,  a  host  of  which  are  at  our 
disposal.  The  most  efficacious  are  those  of  Carlsbad, 
Marienbad,  Hunyadi  Janos,  Friedrichshall,  and  a  newly 
introduced  Spanish  water,  the  Rubinat-Condal.  The 
best  way  to  take  any  of  these  is  to  mix  from  4  to  6  ozs. 
with  an  equal  quantity  of  hot  water,  and  this  is  to  be 
drunk  on  rising,  or  while  dressing.  The  quantity  should 
be  sufficient  to  move  the  bowels  once  or  twice  after 
breakfast,  but  undue  purgation  is  to  be  avoided.  In 
some  cases  it  is  found  that  saline  purgatives  cause  a 
great  deal  of  depression,  and  for  these  they  are  not 
suitable.  Whenever  a  more  decided  purgative  action  is 
required  we  may  have  recourse  to  the  rhubarb  draught 
with  soda  and  magnesia,  to  the  compound  liquorice 
powder,    or    to    colocynth    and    henbane    pills.       For 


CHANGE  OF  AIR  AND  SCENE.  527 

debilitated  subjects  small  doses  of  aloes  are  usually  the 
most  appropriate ;  and  some  effervescing  preparation  of 
magnesium  will  often  answer  the  purpose_,  but  this  drug 
should  not  be  administered  continuously  for  any  length 
of  time. 

The  improvement  of  the  general  health  is  an  all-impor- 
tant object  in  the  treatment  of  dyspepsia,  and  change  of 
air  under  proper  regulations  will  often  do  more  good 
than  any  other  measure.  In  prescribing  this  change 
the  habits  and  tastes  of  the  patient  must^  to  some 
extent  at  least,  be  consulted.  The  town-dweller  will, 
probably,  be  benefited  by  a  change  into  fresh  country 
air,  or  to  the  seaside,  while  a  change  of  an  opposite 
character  will  sometimes  assist  a  patient  depressed  by 
the  tranquillity  and  dulness  of  a  country  life.  In  some 
of  these  cases  the  benefit  is  due  really  to  the  chano;e  of 
environment,  and  not  to  the  hygienic  qualities  of  the 
place.  New  scenes,  agreeable  society,  recreation,  rest, 
or  at  least  freeck)m  from  toil  and  ordinary  avocations, 
assist  very  decidedly  in  the  restoration  of  shattered 
nerves  and  broken  health,  which  are  both  causes  and 
consequences  of  gastric  disorders.  Exercise  is  another 
subject  requiring  careful  attention  ;  it  must  be  adapted 
to   the    powers   and   tastes    of  the  patient.     Walking, 


528  TREATMENT  OF  DYSPEPSIA. 

driving,  and  horse-exercise  are  all  likely  to  be  useful ;  in 
anv  case  fatisrue  must  be  avoided,  and  rest  should  be 
enjoined  after  meals.  It  is  also  well  to  prescribe  half- 
an-hour's  rest  before  meals,  especially  for  weakly 
subjects.  The  Swedish  system  (Dr.  Ling's)  of  medical 
gymnastics,  massage,  or  the  Zander  system  of  exercise 
by  mechanical  means  will  be  serviceable  in  appropriate 
cases.  Manv  muscles  are  thus  brought  into  play  with- 
out undue  fatigue.  When  the  strength  has  improved 
a  sojourn  for  some  weeks  in  a  mountainous  district 
will  tend  to  restore  the  patient  to  perfect  health. 
Attention  to  the  functions  of  the  skin  and  the  use  of 
tepid  baths  will  assist  the  cure. 

With  regard  to  medicines  for  cases  of  dyspepsia  they 
are  sometimes  indispensable,  but  they  should  be  re- 
garded for  the  mo.st  part  only  as  adjuvants  to  more 
rational  measures.  To  improve  the  condition  of  the 
stomach,  and  to  supply  a  constituent  of  the  gastric 
]uice,  often  deficient  in  these  cases,  hydrochloric,  or 
.  nitro-hydrochloric  acid  may  be  given  with  advantage. 
The  following  combination  will  be  found  to  suit  many 
patients: — R  Acid.  Nitro-hydrochloric  Dil.  nxx-xv; 
Tinct.  Nucis  Vom.  nxv-x;  Tinct.  Hyoscyami  nxx-xv; 
Tnfus.    Lupuli   vel   Calumbae,  vel    Chirettae  jj — to   be 


ALKALIES  FOR  ACIDITY.  529 

taken  three  times  a  day,  half-an-hour  before  meals.  It 
may  be  continued  for  several  weeks  ;  the  mouth  should 
be  washed  out  with  water  containing  a  little  sodium 
carbonate  after  each  dose.  When  constipation  is 
present  and  flatulence  is  also  troublesome  I  find  a  pill, 
composed  as  follows,  to  be  most  useful : — R  Podophylli 
Res.  gr.  J ;  Creasoti  v\\'j  Ext.  Col.  Co. ;  Pil.  Rhei  Co. ; 
Jjxt.  Hyoscyami  aa  gr.  iss. — to  be  taken  at  bedtime  as 
required. 

Whenever  there  is  excessive  formation  of  acid  in  the 
stomach,  a  process  which  is  usually  the  result  of  fermen- 
tation, and  is  attended  with  much  pain,  an  alkali,  the 
sodium  bicarbonate,  is  preferable  to  the  hydrochloric 
acid.  It  should  be  given  in  quantity  sufficient  to 
neutralize  the  acid  -,  and  even  if  the  reaction  of  the 
stomach  be  rendered  alkaline,  this  condition  will  be  of 
short  duration,  inasmuch  as  the  bicarbonate  excites  the 
secretion  of  gastric  juice.  Distension  of  the  stomach 
is  by  all  means  to  be  avoided,  for  it  will  add  to  the 
patient^s  discomfort,  and  probably  provoke  retching  or 
vomiting.  The  salt  should  be  given  slowly  and  in 
small  quantities  at  a  time;  a  teaspoonful  should  be 
dissolved  in  about  half  a  tumblerful  of  water  not  too 
cold,  and  mouthfuls  of  this  should  be  taken  at  intervals 

34 


530  TREATMENT  OF  DYSPEPSIA. 

of  several  minutes.  An  indication  for  the  employment 
of  the  soda  is  increased  secretion  of  saliva,  and  a  feel- 
ing of  rawness  or  burning  in  the  throat.  The  alkalies 
should  not  be  given  too  frequently,  but  should  be 
retained  for  acute  attacks  ;  the  administration  of  hydro- 
chloric acid,  as  above  directed,  will  prove  more  efficacious 
for  relieving  the  chronic  state  of  acidity  so  frequent  in 
dyspeptic  cases.  It  is  almost  invariably  serviceable  in 
cases  of  oxaluria,  in  which  the  eructations  often  consist 
of  much  sulphuretted  hydrogen.  For  gouty  dyspepsia 
this  acid  is  often  useful  combined  with  trtij-iv  of  acid, 
hydrocyanic,  dil.  and  a  vegetable  bitter,  and  taken 
before  food.  The  acid  is  also  efficacious  when  given 
before  a  meal,  for  cases  of  pyrosis  in  which  the  fluid 
that  rises  has  an  acid  reaction ;  if  this  symptom  occur 
after  meals  the  alkalies  are  indicated.  For  paroxysmal 
pyrosis  Sir  W.  Roberts  recommends  lozenges,  and 
especially  gum  lozenges.  When  these  are  taken  saliva- 
tion is  promoted,  the  blood  itself  is  made  the  source  of 
the  alkali,  and  the  excessive  acidity  of  the  stomach  is 
neutralized  by  the  passage  downwards  of  the  alkaline 
saliva. 

For  some  cases  of  dyspepsia  in  which  the  prominent 
symptoms  are  pain  at  the  pit  of  the  stoniach  extending 


jRBMEDIES  FOR  FLATULENCB.  531 

to  the  back,  and  the  development  of  flatus,  a  preparation 
of  bismuth  with  a  Httle  nux  vomica  will  often  prove 
valuable.     The  bismuth  appears  to  be  especially   effi- 
cacious when  the  pain  is  of  a  cramp-like  character  and 
comes  on  in  paroxysms.     Dr.  Leared  has  recommended 
the  purified  oxide  of  manganese  as  a  remedy  for  this 
class  of  cases,  and  exceeding  bismuth  in  power.     The 
dose  is  from  three  to  ten  grains  made  into  pills  with 
syrup,  and  taken  three  times  a  day.  For  dyspepsia  with 
foul    eructations   vegetable   charcoal  is    often   a   good 
remedy,  and  the  author  just  quoted  recommends  that  it 
should  be  given  hermetically  sealed  in  gelatine  capsules. 
In  this   country  charcoal  is  occasionally  prescribed  in 
mixtures,  and  in  the  form  of  biscuits  or  lozenges.     The 
two  latter  must,  of  course,  be  thoroughly  mixed  with 
saliva  before  being  swallowed,  and  charcoal  taken  in  this 
way  cannot  be  of  much  efficacy  as   an    absorbent   of 
gases.     Dr.  Leared's  capsules  contain   more  than  ten 
grains   of  charcoal  made  from  vegetable   ivory,  and  of 
these  three  or  four  should  be  taken  at  a  time.    Creasote 
is  also  a  valuable  remedy  for  the  relief  of  flatulence  and 
pain  occurring  after  food.      It  may  be  given  in  doses  of 
one  minim  made  into  a  pill  with  a  little  myrrh.     The 
sulpho-carbonate  of  sodium  is  another  remedy  of  this 


S32  TEUATMENT  OF  DYSPEPSIA. 

class.  The  dose  is  lo  or  15  grains  taken  in  water 
either  before  or  after  meals  according  to  circumstances. 
In  many  cases  of  flatulent  dyspepsia  I  often  see  great 
benefit  from  a  lozenge  prepared  for  me  by  Messrs. 
Squire_,  and  containing  subnitrate  of  bismuth  and 
sulphocarbolate  of  sodium.  One  or  two  of  these  should 
be  taken  either  one  hour  before  or  two  hours  after  a 
meal.  For  dyspepsia  marked  by  hepatic  derangement 
I  find  salicin  and  sodium  salicylate  often  useful.  As  a 
purgative  in  these  cases  a  pill  containing  podophyllin^ 
euonymin,  and  pil.  col.  et  hyoscyam.  will  generally  be 
found  suitable. 

For  so-called  irritative  dyspepsia^  when  pain  comes 
on  after  food  is  taken  and  diarrhoea  is  apt  to  be  set  up, 
arsenic  is  often  a  very  useful  remedy.  In  these  cases 
the  tongue  is  furred  and  its  papillae  red  and  prominent, 
especially  at  the  tip,  and  vomiting  of  food  soon  after 
taking  it  is  a  frequent  symptom.  The  arsenic  should 
be  given  in  doses  of  two  or  three  minims  shortly  before 
meals.  Ipecacuanha  is  useful  in  some  forms  of  dys- 
pepsia. It  may  be  added  to  the  purgatives  with  a  view 
of  increasing  the  secretion  of  mucus  in  the  intestinal 
canal.  One  grain  given  each  morning  is  said  by  Ringer 
to  relieve  constipation  depending  on  great  torpor  of  the 


HEALTH-RESORTS  FOR  DFSPEPSIA.  533 

intestines  and  the  dyspepsia  therewith  associated,  which 
is  "  characterized  by  depression  of  spirits,  some  flatu- 
lence, coldness  of  the  extremities,  and  by  the  food  lying 
on  the  stomach  like  a  heavy  weight."  Pepsin  in  doses 
of  two  to  five  grains,  taken  with  meals,  is  often  useful 
in  these  cases,  and  Benger's  liquor  pepticus  I  find  to 
be  an  excellent  preparation.  As  an  adjuvant  to  all  the 
remedies  just  mentioned  quinine  is  useful  in  most  cases 
of  indigestion,  and  especially  when  the  acute  symptoms 
have  subsided.  Nux  vomica  is  also  a  very  valuable 
remedy,  and  may  be  advantageously  combined  with 
most  other  medicines  suitable  for  dyspeptic  patients. 

In  cases  of  dilatation  of  the  stomach,  which  is  a  not 
un frequent  consequence  of  long-continued  dyspepsia, 
much  improvement  may  sometimes  be  produced  by 
regularly  washing  out  the  organ  with  warm  water.  In 
the  case  of  a  lady,  aged  38,  brought  to  me  by  a  medical 
man  some  time  ago,  this  plan,  carried  out  three  or  four 
times  at  weekly  intervals,  was  attended  with  excellent 
results. 

It  only  remains  to  notice  the  methods  of  treatment 
carried  out  at  the  various  health-resorts  where  the  water 
and  climate  are  suitable  for  dyspeptic  cases.  Much 
good  is  often  obtained  by  a  sojourn  of  four  or  six  weeks 


.534  TRI:A  the  NT  OF  D  TSPEPSIA . 

at  some  one  or  other  of  these  places.  The  water^  the 
diet,  the  change  of  air  and  scene,  the  regular  exercise, 
and  the  daily  routine  all  combine  to  produce  the  desired 
effect,  and  patients  who  in  their  own  houses  are  often 
somewhat  refractory  generally  submit  without  a  murmur 
even  to  severe  restrictions  and  regulations  at  a  foreign 
watering-place.  The  choice  of  the  health-resort  always 
requires  consideration.  Gouty  cases  may  be  sent  with 
advantage  to  Carlsbad,  Marienbad,  or  Vichy ;  more 
delicate  patients  may  go  to  Kissingen  and  afterwards  to 
Schwalbach,  while  such  places  as  Wiesbaden,  Baden- 
Baden,  and  Homburg  will  suit  mild  cases  of  dyspepsia 
presenting  no  very  special  indication.  It  must  never  be- 
forgotten  that  in  this  country  we  have  many  excellent 
health-resorts  suitable  for  cases  of  dyspepsia.  It  is 
only  necessary  to  mention  Buxton,  Bath,  Harrogate, 
and  Woodhall  Spa.  Properly  selected  and  with  good 
■  sanitary  surroundings,  almost  any  country  place  may  be 
utilized  as  a  health-resort.  As  regards  seaside  health- 
resorts,  no  country  in  Europe  presents  so  many  or  such 
a  variety  as  our  own. 


CHAPTER     III. 

NERVOUS  DYSPEPSIA  AND  PERVERTED  APPETITE. 


Causes  of  Nervous  Dyspepsia — Symptoms — 'Gastric  and  Nervous 
Troubles  —  Diagnosis — Treatment — Diet  and  Regimen — 
Exercise — Drugs,  Quinine,  Arsenic,  and  Belladonna — The 
Weir  Mitchell  Treatment  as  for  Neurasthenia — Perversion 
OF  Appetite — Appetite  Abnormally  Increased  —  Symptoms 
AND  Causes — Treatment — Diminution  and  Loss  of  Appetite 
or  Anorexia — Case  and  Treatment — Depraved  Appetite — 
Symptoms  and  Treatment. 


In  the  preceding  chapter  on  Indigestion  in  general_, 
reference  was  made  to  a  form  of  the  complaint  to  which 
the  epithet  ^'  nervous  ^'  may  be  suitably  applied^  inas- 
much as  the  symptoms  make  themselves  felt  for  the 
'most  part  in  the  nervous  system.  As  a  matter  of 
course  the  symptoms  in  question  may  be  associated 
with  various  lesions  of  the  stomachy  such  as  catarrh^ 
ulcer,  or  malignant  disease^  and  it  is  only  when  these 
can  be  excluded  that  we  are  iustified  in  reQ:ardinor  the 
attacks  as  of  neurotic  orisfin. 

o 

Nervous  dyspepsia  is  more  common  in  men  than  in 
womenj  and    it    occurs   for  the  most   part  among  the 


536  NERVOUS  DYSPEPSIA. 

dwellers  in  towns  or  cities,  and  upon  whose  nervous 
energies  demands  are  constantly  being  made ;  such 
patients  are  usually  between  30  and  40  years  of  age. 
The  symptoms  in  many  cases  are  associated  with  those 
of  other  neurotic  complaints,  such  as  neurasthenia, 
hypochondriasis,  and  hysteria.  Prolonged  mental  strain, 
deficiency  of  sleep,  and  sedentary  habits  are  common 
causes  of  nervous  indigestion.  In  other  cases  the  sym- 
ptoms are  associated  with  those  of  anaemia,  and  are  thus 
sometimes  witnessed  in  the  subjects  of  chlorosis  and 
tuberculosis,  and  as  the  result  of  excesses,  sexual  and 
otherwise.  In  other  cases  the  symptoms  are  the  con- 
sequence of  immoderate  use  of  alcohol  and  tobacco ; 
malarial  poisoning,  also,  is  able  to  cause  symptoms  of 
nervous  dyspepsia.  As  of  reflex  origin,  these  latter  are 
sometimes  noticed  in  cases  of  disorders  of  the  uterus, 
ovaries,  kidneys,  and  intestines. 

Nervous  dyspepsia  is  distinguished  from  other  forms 
of  the  complaint  by  the  fact  that  there  are  no  appreci- 
able alterations  in  the  mechanical  and  chemical  pro- 
cesses of  digestion,  but  that  the  preparation  of  the 
food  for  its  absorption  is  accompanied  by  local  troubles, 
and  by  nervous  symptoms  of  a  general  character  having 
their  starting-point  in  the  stomach,  and  propagated  by 


xS  TMP  TOMS  OF  NER  VO  US  B  YSPEPSIA .  537 

reflex  action.  The  symptoms  for  the  most  part  come 
on  after  the  principal  meal,  but  not  until  several  hours 
have  elapsed ;  they  are  not  due  to  errors  or  excesses  of 
any  kind  in  connection  with  the  food  then  taken.  On 
the  contrary,  the  patient  may  have  been  •  careful  as 
regards  both  quality  and  quantity,  yet  at  the  time 
specified  he  is  conscious  of  an  unpleasant  sensation 
of  fulness,  distension,  and  pressure  in  the  epigastrium. 
Sometimes  there  is  more  or  less  decided  pain,  which  is 
relieved  by  pressure  ;  eructation  of  odourless  gaseous 
matters  is  a  frequent  symptom ;  burning  sensations  in 
the  throat  are  less  common,  but  there  is  sometimes 
nausea,  and  an  inclination  to  vomit.  The  patient  feels 
thirsty,  but  has  no  appetite;  the  tongue  maybe  normal, 
but  an  unpleasant  taste  in  the  mouth  is  a  common 
symptom.  Some  patients  complain  of  fulness  and 
constriction  in  the  oesophagus,  and  of  a  feeling  more 
or  less  resembling  the  globus  hystericus.  Constipation 
is  generally  present,  and  various  uncomfortable  sensa- 
tions are  experienced  in  the  intestines. 

The  nervous  symptoms  are,  however,  the  most  trouble- 
some   to    the    patient;    he    complains  of  a   feeling  of 
beating  in  the  head,  coupled  with  that   of  rushing  of 
blood  to  the  part,   of  confusion  of  thought,  noises  in 


538  •       NJESVOUS  DYSPEPSIA. 

the  ears,  spots  or  sparks  before  the  eyes^  headache, 
and  giddiness.  The  spirits  are  depressed^  sleep  is  dis- 
turbed and  unrefreshing  ;  some  patients  are  much 
troubled  with  drowsiness  and  languor,  and  constant 
yawning,  especially  after  eating.  Palpitation  of  the 
heart  and  attacks  resembling  asthma  are  not  un- 
common in  these  patients.  If  vomiting  takes  place, 
nothing  abnormal  is  discoverable  in  the  ejected  matters; 
on  the  contrary,  there  are  evidences  that  digestion  has 
been  well  performed.  The  complaint  must,  therefore, 
be  attributed  to  undue  sensitiveness  of  the  nerves  of 
the  stomach.  The  patient's  condition  is  apt  to  be 
seriously  influenced  by  these  attacks ;  he  becomes  pale, 
and  loses  flesh  and  strength. 

The  diagnosis  of  nervous  dyspepsia  is  sometimes 
difficult ;  the  important  question  for  determination  is 
whether  any  organic  lesion  of  the  stomach  is  the  cause 
of  the  symptoms.  This  latter  question  may  usually 
be  settled  in  the  negative  if  the  symptoms  disappear 
and  the  digestion  be  quite  normally  performed  from 
time  to  time.  The  prognosis  in  cases  of  nervous 
dyspepsia  must  be  regulated  by  the  nature  and  duration 
of  the  symptoms. 

The    treatment    of    this    afl'ection   consists,  first,  in 


[ 


THE  A  tmi:nt  of  ner  ro  us  d  ts  pep  si  a  .       539 

attention  to  diet  and  hygiene ;  and,  secondly,  in  the 
administration  of  certain  drugs.  The  diet  requires 
careful  study,  inasmuch  as  these  patients  differ  con- 
siderably in  their  powers  of  digestion.  One  pre- 
liminary point  must  be  borne  in  mind,  viz.,  that  a 
definite  period  of  rest  should  be  allowed  between 
exercise  and  a  meal,  and  also  after  the  latter  has  been 
taken.  To  sit  down  to  dinner  when  tired,  or  to 
exercise  mind  or  body  while  digestion  is  in  progress, 
will  nullify  all  attempts  at  relieving  the  symptoms. 
As  to  the  diet  itself,  it  should  be  of  a  nutritious,  easily 
digestible  character,  and  the  food  should  be  well  masti- 
cated and  eaten  slowlv.  Stimulants  in  moderation  are 
likely  to  do  good,  but  much  fluid  should  not  be  taken 
during  eating  j  some  hot  claret  and  water  will  be  found 
to  suit  most  cases.  Every  endeavour  should  be  made 
to  secure  a  fair  amount  of  sleep  at  night;  the  exercise 
taken  should  be  proportioned  to  the  strength,  and 
always  short  of  fatigue;  a  change  of  air  to  the  seaside 
or  to  a  mountainous  district  is  generally  desirable  for 
these  patients.  With  regard  to  drugs,  the  most  useful 
are  quinine,  nux  vomica,  and  arsenic ;  if  there  be  much 
pain  belladonna  will  probably  be  serviceable.  The 
arsenic  should,    of  course,  be  given  after  meals;    the 


54°  IJXCJESSIVS  APPETITi;. 

bowels  should  be  kept  open  by  means  of  mild  laxatives, 
such  as  cascara,  anelixir  of  which^  prepared  by  Messrs. 
Squire_,  will  be  found  to  be  quite  palatable^  the  disagree- 
able flavour  of  the  drug  being  completely  masked.  If,  as 
often  happens,  there  be  decided  evidences  of  neuras- 
thenia, the  best  course  to  pursue  will  be  to  place  the 
patient  under  the  Weir  Mitchell  system  of  treatment, 
for  a   description    of  which   the    reader  is    referred  to 

P-  47- 

In  connection  with  nervous  dyspepsia,  some  reference 
must  be  made  to  certain  alterations  or  perversions  of 
appetite  presumably  due  to  nervous  disorder.  Such 
perversion  occurs  in  three  principal  forms  :  in  the  first, 
the  desire  for  food  is  abnormally  increased;  in  the 
second,  it  is  very  much  diminished,  or  altogether  lost ; 
while  in  the  third,  the  appetite  is  directed  towards 
unusual  objects.  All  these  conditions  may  be  quite 
independent  of  organic  disorder  in  the  stomach;  their 
causes  are  those  of  gastric  neuroses  in  general,  and 
they  are  most  frequently  seen  in  the  subjects  of 
hysteria,  neurasthenia,  and  hypochondriasis. 

I.  In  the  first  form  above  mentioned,  the  appetite  is 
excessive  or  voracious;  there  may  be  only  a  slight  increase 
or  a  constant  and  well-nigh  insatiable  craving  for  food. 


EXCJESSIVE  APPETITE.  541 

In  extreme  cases  the  amount  consumed  has  reached 
10,  30,  and  even  60  pounds  weight  in  a  day.  When 
food  is  withheld  there  is  a  feehng  of  uneasiness  and 
even  faintness^  with  an  indescribable  sense  of  sinking 
in  the  stomachy  and  of  a  void  that  must  be  filled.  Such 
patients  are  usually  thin  and  emaciated^  inasmuch  as 
the  food  either  passes  through  the  bowels  without 
being  digested^  or  the  greater  portion  of  it  is  vomited. 
In  other,  instances  the  patients  become  enormously 
fat.  I  have  seen  two  cases  of  neurotic  dyspepsia  in 
mentally  over- worked  men^  in  whom  the  appetite  was 
enormous,  and  constant  craving  and  uneasiness  were 
complained  of  when  food  was  withheld ;  these  patients 
were  thin  almost  to  emaciation. 

With  regard  to  the  cause  of  this  condition  we  know 
that  hunger,  though  always  referable  to  the  stomach, 
may  be  produced  by  impressions  sent  to  the  brain  from 
various  parts  of  the  body,  and  it  would  therefore  appear 
that  a  voracious  appetite  may  depend  either  upon  an 
abnormal  condition  of  the  stomach,  or  upon  the  general 
state  of  the  nutrition.  Excessive  appetite  referable  to 
the  latter  cause  is  seen  in  persons  after  long  fasting, 
and  in  convalescents  from  acute  diseases,  as  well  as  in 
those  suffering  from  disorders  accompanied  by  excessive 


542  EXCESSIVE  APPETITE. 

waste  of  tissue,  as  consumption  and  diabetes.  Dis- 
ordered innervation  of  the  stomach  itself  may  arise 
from  causes  affecting  the  nervous  system  in  general,  as 
in  hysteria,  and  the  same  effect  is  sometimes  due  to 
reflex  action,  as  in  cases  of  worms  in  the  bowels.  In 
some  instances  the  condition  has  been  attributed  to 
preternatural  capacity  of  the  organ,  and  to  enlargement 
of  the  pyloric  orifice,  whereby  the  food  is  allowed  to 
pass  into  the  duodenum  before  digestion  is  completed. 
In  another  class  of  cases  the  excessive  appetite  is  due  to 
habits  of  indulgence,  while  in  others  the  condition  is 
referable  to  the  existence  of  some  cerebral  lesion. 

With  regard  to  treatment,  any  attempt  to  cure  an 
established  habit  of  over-eating  must  be  gradually  made. 
Medicines  should  be  given  to  relieve  any  catarrhal 
condition  that  may  be  present,  whether  of  the  stomach 
or  intestines.  Compression  of  the  abdomen  by  a  tight 
band  has  been  recommended  as  a  palliative.  When  the 
complaint  depends  upon  any  morbid  state  of  the  system 
the  remedies  must  be  directed  towards  the  cure  of  the 
primary  disease.  In  cases  of  downright  gluttony  we 
may  give  with  advantage  small  doses  of  tartar  emetic, 
just  sufficient  to  nauseate  the  patient.  In  dealing  with 
convalescents  we  must  prescribe  the  quantity  and  quality 


LOSS  OF  APPETITE.  543 

of  food  to  be  taken,  and  point  out  the  great  danger 
attendant  upon  excess.  This  caution  is  especially 
necessary  in  cases  of  typhoid  fever  and  dysentery. 

II.  An    opposite    condition,    loss    of    appetite,    or 
anorexia,  accompanies  almost  all  kinds  of  disorders  of 
the  stomach,  and  these  in  their  turn   are  frequent  con- 
comitants  of  febrile  and   other   affections.      In   acute 
gastritis  the  patient  has  no  desire  whatever  for  food, 
and  in  the  chronic  forms  the  appetite  is  generally  much 
diminished,  or,  at  least,  very  irregular.     In  ulcer  of  the 
stomach  there  may  be  no  loss  of  appetite,  but  the  patient 
fears  to  eat  owing  to  the  pain  that  is  produced.     In 
malignant  disease  the  appetite  varies,  but  it  tends  to 
fail  as  time  goes  on,  and  the  secreting  structure  of  the 
stomach  is  destroyed.    Anorexia  is  a  common  symptom 
in  some  hysterical  subjects,  and  is  often  very  difficult  to 
treat,  as   it  is  usually  impossible  to  accept  the  state- 
ments of  the  patient  with  regard  to  the  amount  of  food 
really  taken.     Reference  has  been  made  to  this  subject 
in  a  previous  chapter    (see  p.   107).     A  typical  case  of 
this  character  has  recently  been  placed  on  record  by  Sir 
William  Gull    (see    Lancet,  March    17th,  1888).     The 
patient,  a  girl,  aged   14,  was  healthy  and  well  until  the 
beginning  of  1887,    when,  without  apparent  cause,  she 


544  LOSS  OF  APPJSTITJE. 

began  to  evince  a  repugnance  to  food^  and  soon  after 
refused  to  take  any  whatever^  except  a  small  quantity  of 
tea  or  coffee.  As  a  matter  of  course^  in  a  few  weeks 
she  became  extremely  emaciated^  weighing  only  4  stone 
7lbs.,  her  height  being  5ft.  4in.  She  was  placed  under 
the  care  of  a  hospital  nurse,  who  was  ordered  to  ad- 
minister light  food  every  few  hours.  In  six  weeks  the 
patient  had  much  improved,  and  she  progressed  steadily 
toward  recovery.  Sir  William  Gull  refers  to  a  curious 
feature  in  this  as  in  other  cases^  viz,,  the  persistent  desire 
to  be  on  the  move_,  though  the  emaciation  was  so  great 
and  the  nutritive  functions  so  much  reduced.  In  1885 
I  met  with  a  case  of  profound  emaciation  from  loss  of 
appetite  in  a  young  lady,  aged  17,  who  presented  most 
of  the  symptoms  described  by  Sir  W.  Gull ;  she  rapidly 
improved  under  enforced  feeding.  In  some  cases,  which 
come  under  the  heading  of  nervous  anorexia,  the  dis- 
taste for  food  is  due  to  the  pain  consequent  on  eating. 

Cases  of  nervous  anorexia  must  be  treated  according 
to  circumstances  :  in  hysterical  cases  a  nurse  is  always 
required,  and  the  exhibition  of  a  little  firmness  will 
generally  prove  sufficient.  For  other  patients  change 
of  air,  tonics,  especially  quinine  and  nux  vomica, 
and  stimulants  in  moderation  will  tend  to  effect  a  cure. 


DEPRAVED  APPETITE.  545 

in.  Examples  of  depraved  appetite  are  most  often 
afforded  by  hysterical  and  chlorotic  subjects,  and  there 
is  scarcely  any  object,  which  can  be  swallowed,  which 
the  patients  will  not  endeavour  to  introduce  into  the 
stomach.  Pregnant  women  sometimes  exhibit  remark- 
able symptoms  of  this  kind.  Indigestible  substances, 
such  as  slate  pencil,  chalk,  clay,  paper,  and  even 
offensive  and  disgusting  materials  are  thus  taken. 
Such  practices  are  sometimes  indulged  in  from  time  to 
time;  occasionally  they  become  habitual,  and  chronic 
gastritis  and  general  disorder  are  thus  induced.  The 
practice  may  depend  upon  some  form  of  gastric  irrita- 
tion, upon  deranged  innervation  of  the  stomach,  or  upon 
cerebral  disorder.  When  chalk  is  swallowed  it  is  possible 
that  undue  acidity  of  the  stomach  has  created  a  desire  for 
alkalies,  and  the  swallowing  of  rough  hard  substances 
may  have  for  its  object  the  relief  of  feelings  of  sinking. 

In  treating  such  cases  the  general  state  of  the  system 
requires  special  attention.  Any  existing  gastric  disorder 
should  be  relieved  by  antacids,  tonics,  and  anodynes 
according  to  circumstances.  The  diet  should  be  care- 
fully regulated,  and  every  attempt  made  to  improve  the 
mental  condition  of  the  patient,  and  to  restore  the 
appetite  to  a  normal  state. 

35 


CHAPTER    IV. 

GASTRALGIA— GASTRODYNIA— CARDIALGIA. 

Pain  in  the  Stomach  as  a  definite  Complaint — Causes — Con- 
ditions UNDER  WHICH  IT  OcCURS — GaSTRALGIA  IN  GoUTY  SUB- 
JECTS— In  Locomotor  Ataxy — Of  Reflex  Origin — Due  to 
Renal  Disease — Symptoms — Duration  and  Exciting  Causes  of 
Paroxysms — Spasmodic  form  of  Gaspralgia— Diagnosis,  from 
Intercostal  Neuralgia,  Myalgia,  Colic,  Peritonitis,  Gall- 
stones, etc.,  and  from  Gastric  Disorders,  as  Ulcer,  Cancer, 
and  Catarrh — Prognosis  and  Treatment  —  Laxatives  — 
Quinine  —  Arsenic  —  Alkalies  —  Ipecacuanha  —  Morphine 
Strychnine,  Chloral,  Electricity  —  Treatment  of  Gouty 
Cases. 

Pain  in  the  stomach  is  a  symptom  of  many  organic 
diseases  of  this  portion  of  the  alimentary  canal,  and 
especially  of  cancer  and  ulcer.  It  also  occurs  in  several 
forms  of  dyspepsia ;  but  in  another  class  of  cases  it 
appears  to  be  a  pure  neurosis  and  independent  both  of 
anatomical  change  and  of  disordered  functions  of  the 
stomach.  It  would  then  seem  to  be  a  neuralgia  of  the 
sensory  nerves  of  the  organ,  and  is  probably  due  to 
perverted  nutrition  of  these  structures.  The  stomach  is 
by  far  the  most  frequent  seat  of  abdominal  neuralgia 
(Allbutt). 

Gastralgia  is  more  frequent  in  women  than  in  men^ 


CAUSES  OF  GASTRALGIA.  547 

and  the  majority  of  the  suflTercrs  are  between  fifteen  and 
forty-five  years  of  age.  It  tends  to  die  out  in  middle 
life^  and  is  less  often  attended  with  vomiting  as  age 
increases.  In  this  respect  it  resembles  migraine,  with 
which  it  is  often  associated.  It  is  rare  in  yoinig  children, 
but  not  uncommon  in  elderly  women. 

Pain  in  the  stomach  of  purely  nervous  origin  is  a  com- 
mon symptom  in  chlorosis_,  and  in  conditions  of  debility 
.and  malnutrition  in  general ;  it  is  thus  often  observed  in 
persons  convalescing  from  acute   diseases,  and  in  the 
subjects  of  nervous  exhaustion  from  depressing  emotions, 
anxiety,  etc.     It  is  also  common  in  certain  affections  of 
the   system  in  general,  both  of  an  infectious  and  of  a 
non-infectious   character.      Thus  in  gouty  subjects  an 
attack  of   gastralgia  sometimes  precedes  the  articular 
inflammation,   or  occurs   instead   thereof.      In  a   third 
class  of  cases  the  gastric  pain  follows  the  subsidence  of 
the  articular  symptoms,  and  especially  when  these  latter 
have  been  cut  short  by  cold  applications  to  the  affected 
part.     The  gastralgia  is  then  apt  to  be  violent,  and  is  a 
symptom  of   grave   import."^     Pain  in  the   stomach  is 


*  For  a  detailed  account  of  the  symptoms  of  this  form  of  gfastralgfia, 
see  the  Author's  work  on  "  Gout  and  its  Relations  to  Diseases  of  the  Liver 
and  Kidneys."  5th  Edit.,  Chapter  V. 


548  CAUSES  OF  GASTRALGIA. 

sometimes,  but  far  less  often,  experienced  in  the  course 
of  chronic  rheumatism;  it  is  not  of  uncommon  occurrence 
in  connection  with  malarious  fevers.  In  such  cases  it 
comes  on  at  regular  intervals  with  the  other  symptoms,, 
which  may  be  of  a  less  marked  character,  but  which^ 
with  the  pain,  are  cured  or  prevented  by  antiperiodics.. 
Dr.  Austin  Flint  has  recorded  a  case  in  which  gastralgia 
took  the  place  of  the  cold  stage  of  malarious  fever,  and 
was  followed  by  the  hot  and  sweating  stages. 

Severe  pain  in  the  stomach  is  a  frequent  symptom 
in  hysteria  and  hypochondria,  and  is  apt  to  be  associated 
with  other  neuralgic  troubles.  It  is  also  a  symptom  of 
grave  lesions  of  the  nervous  system,  such  as  spinal 
sclerosis,  myelitis,  and  softening  of  the  brain.  It  is 
a  peculiar  feature  of  locomotor  ataxy,  in  which  the 
attacks  sometimes  assume  great  intensity,  and  are 
attended  by  vomiting,  faintness,  and  disturbed  action 
of  the  heart.  These  symptoms  are  wont  to  recur  from 
time  to  time,  and  closely  resemble  those  of  acute  gouty 
disorder  of  the  stomach.  Dr.  Buzzard,  indeed,  suggests 
that  many  cases  of  so-called  ^'  gout  in  the  stomach  " 
would  be  found,  if  examined  by  the  light  of  our  present 
knowledge,  to  be  examples  of  tabes  dorsalis,  with 
gastric   crises.      It  must  be  remembered   that   severe 


CAUSES  OF  GASTRALGIA,  549 

gastric  attacks  are  sometimes  witnessed  in  persons  who, 
although  examples  of  tabes  dorsalis,  ^^  show  at  the 
time  no  sign  of  inco-ordination  of  movement." 

Attacks  of  gastralgia  are  not  unfrequently  of  reflex 
•origin,  being  induced  by  affections  of  various  abdominal 
organs.  Instances  of  such  causation  are  often  met 
with  in  women  suffering  from  uterine  or  ovarian 
disorders  ;  the  pain  generally  comes  on  at  the  menstrual 
periods  and  subsides  with  the  discharge.  Pregnant 
•women,  too_,  sometimes  suffer  from  gastralgi'a^  and  less 
frequently  the  pain  is  associated  with  affections  of  the 
kidneys,  liver,  pancreas,  spleen,  and  intestines.  Gas- 
tralgia is  often  associated  with  asthma,  and  sometimes 
one  member  of  a  family  suffers  from  the  former  and 
others  from  the  latter  complaint. 

In  not  a  few  cases  of  gastralgia  no  obvious  cause  is 
discoverable.  A  history  of  sexual  and  alcoholic  excesses 
can  sometimes  be  ascertained,  and  occasionally  there  is 
evidence  of  disordered  renal  secretion.  The  urine 
should  always  be  examined ;  the  gastric  disorder  may 
be  the  first  indication  of  mischief.  The  lungs,  too, 
should  not  be  passed  over,  for  gastralgia  is  sometimes 
severe  in  the  earliest  stage  of  pulmonary  phthisis. 

An  attack  of  gastralgia  may   come  on  suddenly  and 


550  SYMPTOMS  OF  GASTRALGIA. 

without  warning,  or  it  may  be  preceded  by  such  pre- 
monitory symptoms  as  a  feeling  of  distension  in  the 
stomach,  nausea  and  eructations,  vomiting,  depression 
of  spirits,  etc.  The  pain,  once  set  in,  soon  becomes- 
extremely  severe,  and  is  described  by  the  patients  as 
boring,  burning,  pricking,  smarting,  or  cramp-like;  it 
is  felt  principally  in  the  cardiac  and  epigastric  regions, 
but  is  apt  to  extend  to  the  back  and  up  between  the 
scapulae  and  to  the  umbilical  and  hypochondriac  regions. 
Sometimes  the  attacks  resemble  those  of  angina;  the 
pain  shoots  down  the  left  arm,  and  the  pulse  falls  to 
forty  or  even  thirty  beats  per  minute.  I  have  seen 
several  patients  of  both  sexes  in  whom  the  gastralgia 
was  attended  by  pains  shooting  down  the  left  arm  and 
up  into  the  left  shoulder  joint.  The  patients  find  that 
firm  pressure  will  relieve  the  pain,  and  they  accordingly 
apply  their  hands  to  the  epigastrium  and  over  the  heart,, 
or  press  the  abdomen  against  some  firm  substance ; 
others  feel  better  when  lying  on  the  back,  and  others,, 
again,  when  sitting  in  a  chair  with  the  body  bent  forwards 
as  much  as  possible.  The  deep-seated  pain  may  be  ac- 
companied by  superficial  hyperaesthesia.  When  the  pain 
is  at  its  height  the  feeling  of  prostration  becomes  intense  ; 
the  face  is  pale  and  the  skin  cold  ;  the  pulse  is  small  and 


SYMPTOMS  OF  GASTRALGIA.,  551 

irregular,  and  either  more  or  less  frequent  than  natural; 
perspiration  breaks  out  on  the  face,  neck,  and  hands ; 
sometimes  there  are  muscular  twitchings,  amounting,  it 
may  be,  to  convulsions.  Dyspnoea  and  cough  are  not 
unfrequent,  especially  in  hysterical  subjects.  The  termi- 
nation of  the  attack  is  often  preceded  by  fluid  eructa- 
tions, yawning  and  vomiting,  and  ineffectual  attempts 
and  retching  may  remain  for  some  time  after  the  pain 
has  subsided. 

On  examining  the  patient  during  the  continuance  of 
the  pain  the  abdomen  is  generally  found  to  be  drawn 
in  ;  its  walls  are  hard  and  firm,  and  the  pulsations  of  the 
aorta  are  freely  visible.  In  other  instances  the  abdomen 
is  distended  and  the  stomach  is  felt  as  a  globular 
swelling  at  the  upper  part ;  occasionally  spasmodic 
movements  of  the  stomach  and  bowels  may  be  observed. 
Constipation  is  often  present,  and  the  colon  can  some- 
times be  detected  on  percussion.  The  urine  is  for  the 
most  part  scanty  and  high-coloured,  except  in  hysterical 
subjects,  in  whom,  after  the  subsidence  of  the  attack, 
abundant  discharge  of  watery  urine  is  a  frequent 
symptom.  A  temporary  condition  of  albuminuria, 
with  hyaline  casts,  and  lasting  for  a  few  days,  has  been 
noticed  in  some  cases.     The  appearance  is  due  to  the 


552  SYMPTOMS  OF  GASTRALGIA. 

diminution  of  blood-pressure  in  the  renal  artery,  which 
is  caused  by  the  pain. 

Paroxysms  of  gastralgia  vary  much  as  regards  their 
duration:  sometimes  the  attacks  are  over  in  a  few 
minutes,  and,  on  the  other  hand,  they  may  last  for 
hours,  with  remissions  and  exacerbations.  There  is  a 
corresponding  difference  as  regards  recurrences  :  daily 
attacks  of  greater  or  less  severity  are  sometimes  experi- 
enced, in  other  cases  long  intervals  occur  between  the 
attacks.  When  the  latter  are  associated  with  malarial 
influence,  they  are  wont  to  recur  at  uniform  intervals 
and  at  the  same  hour  of  the  day.  In  women  they  are 
apt  to  become  prominent  shortly  before  and  during  the 
menstrual  periods.  In  some  attacks  no  obvious  exciting 
cause  is  discoverable ;  in  others  there  has  been  undue 
mental  or  bodily  exertion.  Sometimes  the  attacks  are 
attributable  to  prolonged  abstinence  from  food,  and  are 
relieved  by  eating,  to  recur  when  the  stomach  is  again 
empty ;  not  a  few  of  these  patients  are  from  time  to 
time  conscious  of  feelings  of  intense  hunger,  while 
some  of  them  exhibit  signs  of  perversion  of  appetite  and 
desire  indigestible  and  extraordinary  articles  of  food. 
In  some  patients  the  attacks  are  the  result  of  taking 
particular  articles,  such  as  hot  tea;  and  the  suffering 


SYMPTOMS  OF  GASTRALGIA.  5^3 

after  food  may  be  so  great  as  to  lead  to  complete  absti- 
nence for  many  hours.  Other  neuralgic  affections 
sometimes  alternate  with  gastralgia^  and  of  these 
migraine  and  intercostal  neuralgia  are  the  most  com- 
mon. 

Attacks  of  gastralgia^  of  which  the  prominent  features 
are  spasmodic  pain  and  contraction  of  the  walls  of  the 
stomach,  have  been  regarded  as  constituting  a  separate 
neurosis,  but  there  is  no  just  reason  for  regarding  them 
otherwise  than  as  a  variety  of  the  type  already  described. 
The  symptoms  are  especially  apt  to  be  excited  by  indi- 
gestible or  irritating  articles  of  food  or  drink,  such  as 
cold  water  in  excess,  ices,  etc.,  and  gastric  pain  of  this 
character  is  not  uncommon  in  gouty  subjects,  and  in 
some  persons,  as  a  result  of  severe  mental  emotion. 
The  pain  is  described  as  intense,  of  a  twisting,  constric- 
tive, griping  kind,  coming  cm  suddenly  and  most  marked 
near  the  pylorus ;  it  may,  however,  extend  across  the 
epigastrium  and  even  up  the  oesophagus.  In  severe 
cases  the  patients  seek  relief  by  lying  on  the  abdomen, 
or  rolling  about.  The  symptoms  of  collapse,  as  described 
in  a  former  paragraph,  become  very  marked,  and  may 
actually  end  in  death,  as  a  result  of  failure  of  the  heart's 
action. 


554  DIAGNOSIS  OF  GASTRALGIA. 

The  diagnosis  of  gastralgla  is  often  a  task  of  some 
difficulty.  The  points  to  be  determined  are,  first,  that 
the  pain  is  really  situated  in  the  stomach,  and  secondly 
that  it  is  not  due  to  organic  lesions  of  that  viscus* 
The  ailments  other  than  gastric,  for  which  it  may  be 
mistaken,  are:  intercostal  neuralgia;  myalgia  of  the 
abdominal  muscles  ;  colic  ;  circumscribed  peritonitis  ; 
pain  due  to  the  passage  of  gall-stones,  and  pain  radiated 
from  neighbouring  organs.  In  intercostal  neuralgia  the 
pain  can  be  traced  along  one  or  more  intercostal  spaces 
as  far  back  as  the  vertebral  column;  tender  spots  are 
generally  discoverable,  and  there  is  an  absence  of  gastric 
symptoms  other  than  the  pain.  In  myalgia  of  the  abdo- 
minal muscles,  the  pain  is  of  a  more  continuous  and  less 
paroxysmal  character;  it  is  increased  by  pressure  and 
movement;  it  changes  its  seat  from  time  to  time,  and 
is  relieved  when  the  patientf  lies  on  his  back  so  as  to 
relax  the  abdominal  muscles.  In  colic  the  pain  is  not 
confined  to  one  spot,  but  moves  from  place  to  place, 
and  is  accompanied  by  flatulent  distension  of  the 
abdomen.  In  circumscribed  peritonitis,  the  affected 
part  is  excessively  tender  on  pressure;  the  pain  is  con- 
tinuous rather  than  paroxysmal,  and  is  attended  with 
febrile  symptoms.     The  history  of  the  case  will  also 


DIAGNOSIS  OF  GASTRALGIA.  555 

guide  the  diagnosis.  In  cases  of  gall-stone  colicj  the 
pain  is  especially  felt  over  the  gall-bladder,  at  the  outer 
border  of  the  right  rectus  abdominis  muscle,  close 
to  the  margin  of  the  thorax,  its  onset  is  frequently 
attended  by  rigors  and  vomiting;  there  are  often 
signs  of  jaundice,  and  the  gall-stones  may  be  after- 
wards found  in  the  stools.  With  re2:ard  to  affections 
of  other  organs,  in  renal  colic,  in  pericarditis,  and  in 
pleurisy,  there  may  be  more  or  less  epigastric  pain,  but 
its  true  source  will  be  discovered  on  careful  examination 
and  by  observation  of  other  symptoms. 

Havins;  determined  that  the  stomach  is  the  seat  of 
the  pain,  the  next  point  for  investigation  i^  whether 
any  anatomical  changes  exist  that  w'ould  account  for 
the  suffering,  or  whether  the  latter  is  purely  of  nervous 
origin.  Pain  is  a  prominent  symptom  of  gastric  ulcer, 
but  is  then  much  aggravated  by  taking  food  and  is  not 
relieved  but  increased  by  pressure ;  it  is,  moreover,  often 
associated  with  vomiting  of  blood.  The  pain  is  of  a 
dull  gnawing  character^  localized  in  the  middle  of  the 
epigastrium.  In  cancer  the  pain  is  not  so  spasmodic 
and  so  severe  as  in  some  attacks  of  gastralgia ;  vomit- 
ing is  a  prominent  symptom,  and  the  ejected  matters 
contain  a  much  diminished  proportion   of  hydrochloric 


556  PROGNOSIS  OF  GASTEALGIA. 

acid.  Other  points  to  be  considered  are:  the  age  of 
the  patient ;  the  presence  of  cancerous  cachexia;  the 
rapid  course  of  the  symptoms ;  the  presence  of  a 
tumour  in  the  epigastrium,  and  sometimes  of  enlarged 
glands  above  the  left  clavicle.  Inflammatory  affections 
of  the  stomach  are  excluded  by  the  absence  of  thirst, 
tenderness,  and  fever,  and  by  the  intermittent  character 
of  the  pain. 

The  prognosis  of  gastralgia  is  favourable  as  regards 
life,  but  the  complaint  is  often  a  very  obstinate  one. 
When  dependent  on  an  obvious  and  removable  cause, 
the  prospect  of  cure  is  much  more  favourable.  In 
mild  cases  the  attacks  do  not  much  influence  the 
general  condition  of  the  patient ;  but  a  more  serious 
result  is  v^itnessed  when  the  attacks  are  severe  and 
frequent,  and  the  patient^s  appetite  is  much  disturbed. 
This,  however,  is  a  somewhat  rare  consequence,  as 
compared  with  the  results  of  chronic  gastric  catarrh  in 
which  the  digestive  functions  may  be  much  disordered 
and  the  patient  may  lose  flesh  and  strength. 

Treatment.  There  are  two  principal  objects  to  be  ful- 
filled :  the  causes  of  the  suffering  should  be  inquired 
into  and  dealt  with  as  far  as  possible,  and  means  must 
be  adopted  for  relieving  the  patient  during  the  attacks. 


TREATMENT  OF  GASTRALQIA.  557 

Rest  is  an  important  item  in  the  treatment^  and  when 
coupled  with  warmth  and  comfort  will  often  do  much 
towards  effecting  a  cure. 

Conditions  of  debility  will  require  tonic  treatment  of 
all  kinds^  and  particularly. the  preparations  of  iron.  In 
most  cases  of  gastralgia^  laxatives  adapted  to  the  circum- 
stances of  the  case  will  be  found  beneficial.  When 
there  is  a  history  of  exposure  to  malarious  influences, 
quinine  is_,  of  course_,  indicated,  and  if  it  fail  to  relieve, 
arsenic  may  be  given  in  doses  of  w\  iij-v  of  the  Liquor 
Arsenicalis  three  times  a  day  after  meals.  The  same 
drug  is  often  very  serviceable  in  ordinary  cases.  If 
ovarian  or  uterine  disorder  be  present,  appropriate  treat- 
ment will  generally  cure  the  gastralgia.  For  attacks 
occurring  in  gouty  subjects,  we  must  in  the  intervals 
have  recourse  to  alkalies  and  purgatives,  and  above  all 
things  regulate  the  diet  in  every  particular.  In  cases  of 
gastralgia,  attended  -by  nausea  and  vomiting,  ipeca- 
cuanha is  sometimes  a  useful  remedy.  My  friend  Dr. 
Gordon  thus  treated  a  case  of  this  character,  the  patient 
being  a  young  lady,  aged  twenty.  The  pain  and  vomit- 
ing had  lasted  for  a  month,  and  were  relieved  in  two 
days  by  drop  doses  of  ipecacuanha  wine,  taken  every 
half-hour,  until  twenty  drops  were  taken. 


558  tri:atment  of  gastralgia. 

To  relieve  the  pain  during  the  paroxysms,  warm 
fomentations  may  be  apphecl  over  the  stomach  and 
gr,  ^-\  of  morphine  may  be  injected  hypodermically. 
For  symptoms  of  faintness  or  collapse  we  may  give  a 
few  drops  of  aether  or  ammoniated  tincture  of  valerian 
on  a  lump  of  sugar.  The  late  Dr.  Anstie  recommended 
the  hypodermic  injection  of  strychnine  gr.  -^\q  to  relieve 
the  pain.  There  is,  he  says,  ^'^no  such  remedy  for 
gastralgia  as  this."  Chloral  hydrate,  belladonna,  and 
bismuth  may  be  tried  if  these  fail.  Some  German 
authorities  recommend  washing  out  the  stomach  with 
warm  water  holding  carbonic  acid  in  solution.  Others 
assert  that  electricity  is  always  serviceable  in  gastralgia, 
and  that  failure  under  the  use  of  this  remedy  indicates 
some  oro;anic  lesion.  If  the  constant  current  be  used, 
the  positive  pole  is  placed  over  the  painful  spot,  while 
the  negative  is  applied  to  the  axilla  or  to  the  vertebral 
column.  The  rheophores  should  remain  in  position 
for  from  five  to  ten  minutes,  and  a  somewhat  strong 
current  is  necessary.  The  faradic  current  has  been 
found  useful  in  some  cases,  and  is  most  conveniently 
applied  by  placing  both  poles  over  the  epigastrium.  It 
has  also  been  recommended  that  while  one  electrode  is 
kept  in  this  position,  the  other  by  means  of  an  elastic 


TREATMENT  OF  GASTRALGIA.  559 

tube    should    be  passed   into    the  stomach,  previously 
filled  with  warm  water. 

For  attacks  of  gastralgia  occurring  in  gouty  subjects, 
morphine  must  be  avoided,  but  there  is  no  objection  to 
the  subcutaneous  use  of  atropine.  At  the  same  time 
warm  fomentations  must  be  assiduously  applied,  and  if 
the  pain  prove  obstinate,  we  may  have  recourse  to 
sinapisms,  or  to  friction  with  chloroform  liniment. 
The  legs  should  also  be  placed  in  hot  mustard  and 
water.  It  must  be  remembered  that  the  attacks  in 
these  subjects  are  often  associated  with  undue  acidity 
in  the  stomach,  and  it  is  therefore  desirable  to  give  ]o 
or  15  grains  of  bicarbonate  of  sodium  at  short  intervals. 
After  the  attack  has  subsided  a  purgative  will  generally 
be  desirable,  and  the  treatment  and  regimen  adapted  to 
the  uric  acid  diathesis  should  be  carefully  prescribed. 
Change  of  air  will  almost  certainly  do  good,  and  gouty 
cases  of  this  complaint,  like  most  others,  will  be  bene- 
fited by  warmth,  rest,  comforts,  and  freedom  from 
anxiety  and  worries. 


CHAPTER   V. 

NERVOUS  VOMITING  AND  ERUCTATIONS. 


Phenomena  of  Vomiting — Nervous  Vomiting — Reflex  Causes — 
Mental  Impressions — Organic  Nervous  Lesions — Peripheral. 
Irritation — Disorders  of  the  Abdominal  Organs  —  Dis- 
orders OF  the  Sexual  Organs — Toxic  Causes — Symptoms- 
op  Nervous  Vomiting — Diagnosis  and  Prognosis — Treat- 
ment, Causal  and  Symptomatic — Ice,  Anodynes,  Cocaine, 
Bromide  of  Potassium,  etc. — Nervous  Eructations  —  Sym- 
ptoms— Sources  of  the  Gas — Case  of  Nervous  Eructations — 
Treatment. 


Vomiting  is  a  common  symptom  of  many  affections 
of  the  stomach_,  the  act,  as  a  matter  of  course,  being 
accomplished  through  the  instrumentahty  of  the  nervous, 
system.  A  lesion  in  the  gastric  tissues  or  the  contents 
of  the  stomach  cause  irritation  of  the  nerves;  this 
is  conveyed  to  the  vomiting  centre  in  the  medulla 
oblongata,  and  thence  to  the  diaphragm  and  to  certain 
abdominal  muscles,  and  to  the  stomach  itself,  the  car- 
diac orifice  of  which  is  opened  by  the  longitudinal 
muscular  fibres.  These  results  are  often  witnessed 
after  improper  food  and  excess  in  alcoholic  drinks. 
Vomiting  due  to  gastric  causes  is  easily  intelligible  ; 


NERVOUS   VOMITING.  561 

but  the  process  is  a  symptom  of  many  affections  of 
other  parts  of  the  body,  the  stomach  itself  in  such 
cases  being  quite  free  from  disease. 

Thus  nervous  vomiting  often  occurs  as  a  consequence 
of  direct  irritation  of  the  vomiting  centre,  which  is 
closely  associated  with  the  centre  for  respiration,  as  is 
shown  by  the  fact  that  the  latter  is  excited  by  emetics, 
that  their  action  is  usually  preceded  by  increased  respira- 
tory movement,  and  that  nausea  may  be  overcome  by 
rapid  and  deep  respirations.  Direct  irritation  of  the 
vomiting  centre  may  be  caused  by  injuries  to  the  head, 
tumours,  haemorrhage,  etc.  Nervous  vomiting  is,  how- 
ever, more  often  due  to  reflex  causes,  such  as  disorders 
of  the  brain  and  spinal  cord.  For  the  effect  to  be  pro- 
duced, it  is  by  no  means  necessary  that  such  disorder 
should  be  of  an  organic  kind.  In  many  persons,  violent 
mental  excitement  and  impressions  made  upon  the 
nerves  of  special  sense,  whether  by  disagreeable  odours, 
tastes  or  sights,  and  in  some  even  the  remembrance  of 
such  things,  are  apt  to  provoke  nausea  and  vomiting. 
I  have  met  with  several  persons  in  whom  these  symptoms 
were  liable  to  occur  as  results  of  mental  excitement. 
With  regard  to  organic  lesions  of  the  central  nervous 
system,  it  is  sufficient  to  mention  meningeal  affections 

36 


562  CAUSES  OF  NERVOUS  VOMITING. 

of  all  kinds^  inflammation,  tumours,  haemorrhage,  etc. 
In  cerebral  tumours,  vomiting  is  a  very  common  and 
obstinate  symptom ;  it  is  also  frequently  associated 
with  functional  disorders  as  hemicrania  and  vertigo,  and 
with  such  genera]  neuroses  as  hysteria  and  neurasthenia. 
In  aflTections  of  the  spinal  cord  violent  and  obstinate 
vomiting  is  most  often  seen  in  connection  with  tabes, 
these  so  called  "gastric  crises  "  being  a  peculiar  feature 
of  this  disease.  Vomiting  is  far  less  common  in  myelitis, 
sclerosis,  and  other  affections  of  the  spinal  cord. 

Peripheral  irritation  of  the  most  varied  kind  is  a  com- 
mon cause  of  nervous  vomiting,  and  some  individuals 
are  very  susceptible  in  this  respect.  Nausea  and  vomit- 
ing are  excited  in  some  persons  by  irritating  the  external 
-auditory  meatus;  in  others,  by  tickling  the  feet  or  the 
axillae.  It  is  a  very  common  experience  for  vomiting  to  be 
induced  by  tickling  the  fauces  or  the  base  of  the  tongue, 
and  this  knowledge  is  often  turned  to  practical  use. 
Tumours  and  other  affections  of  the  nasal  mucous 
membrane,  and  bronchial  disorders,  e.g.,  asthma  and 
Avhooping  cough,  not  unfrequently  cause  vomiting,  and 
the  same  symptom  is  often  troublesome  in  cases  ot 
heart-disease. 

Disorders    of    the    abdominal    organs    often    induce 


CAUSES  OF  NERVOUS  VOMITING.  563 

paroxysms  of  nervous  vomiting.  Irritation  of  the  gall- 
ducts  or  of"  the  pelvis  of  the  kidney  or  ureters,  caused 
by  the  passage  of  calculi^  almost  invariably  causes  vomit- 
ing; and  the  same  result  often  follows  contusions  of 
the  abdomen.  The  irritation  may  likewise  proceed  from 
the  mucous  coat  of  the  intestines  as  in  cases  of  worms 
and  foreign  bodies.  Vomiting  is  also  a  constant  sym- 
ptom of  intestinal  strangulation^  and  it  is  not  unfrequent 
in  peritonitis^  even  when  the  serous  membrane  cov^ering 
the  stomach  is  not  implicated. 

Disorders  of  the  sexual  organs  are  frequent  causes  of 
vomiting.  Thus  the  symptom  is  wont  to  occur  in  con- 
nection with  various  forms  of  dysmenorrhoea,  with 
malpositions  of  the  uterus  and  parametritis  ;  in  some 
women  the  normal  discharge  of  the  uterine  functions, 
as  during  menstruation,  is  attended  with  nausea  and 
vomiting,  and  the  occurrence  of  the  same  symptoms 
during  pregnancy  is  a  matter  of  common  experience. 
In  male  patients,  injuries  to  the  testicle,  epididymitis, 
and  orchitis  are  often  attended  by  nausea  and  vomiting. 

In  another  series  of  cases  the  symptom  is  due  to 
toxic  causes,  examples  of  which  are  to  be  found  in 
uraemia,  jaundice,  and  in  the  early  stages  of  some  in- 
fectious  fevers.     The  effects    of   several    medicines    in 


564  SYMPT03IS  OF  NERVOUS  VOMITING. 


producing;  vomiting  is  well  known,  and  the  symptom  is 
one  of  the  drawbacks  which  occasionally  attends  the 
administration  of  other  medicines,  notably  the  prepara- 
tions of  opium  in  some  patients.  The  vomiting  of 
drunkards  belongs  to  this  category. 

There  are,  of  course,  no  anatomical  changes  to  be 
found  in  the  stomach  in  cases  of  purely  nervous  origin ; 
but  in  some  cases  lesions  have  been  discovered  in  the 
nuclei  of  the  vagus  after  death. 

The  symptoins  of  nervous  vomiting  present  certain' 
peculiarities.  They  are  easily  induced  by  causes  acting 
upon  the  nervous  system,  and  are  not  necessarily  con- 
nected with  the  taking  of  food.  Sometimes  they  occur 
when  the  stomach  is  empty ;  pregnant  women,  as  is 
well  known,  are  most  often  troubled  in  the  early  morn- 
ing. The  matters  ejected  are  but  little  changed,  and 
signs  of  fermentation  are  seldom  discoverable.  The 
attacks  of  nervous  vomiting  last  for  variable  periods,, 
and  do  not  terminate  when  the  stomach  is  empty;  with 
the  cessation  of  the  symptoms  the  discomfort  is  at  an 
end,  but  after  violent  attacks  there  may  be  some  amount 
of  collapse  with  pallor  and  coldness  of  skin  and  clammy 
perspiration.  Certain  varieties  in  the  symptom  have 
been   described.      Thus,    in   some    cases    the   cardiac 


DIAGNOSIS  OF  NERVOUS   VOMITING.  565 

•orifice  is  principally  affected,  and  vomiting  soon  follows 
the  taking  of  food.  In  other  cases  the  pylorus  is  the 
seat  of  the  trouble,  and  food  is  retained  in  the  stomach 
for  some  hours  after  being  taken. 

The  general  health  of  these  patients  not  unfrequently 
remains  unchanged  :  they  may  look  fairly  well,  and  not 
lose  weight.  An  opposite  condition  of  things  is,  how- 
ever, sometimes  witnessed,  the  patients  losing  flesh 
.and  strength,  and  eventually  falling  a  prey  to  tubercle. 
The  appetite  varies,  the  patients  generally  complain  of 
thirst.  No  particular  changes  are  discoverable  in  the 
iibdomen;  only  after  violent  attacks  is  there  pain  and 
tenderness  in  the  epigastrium.  In  hysterical  subjects 
the  urine  is  often  scanty  before  an  attack,  and  is  freely 
discharged  afterwards  ;  urea  has  been  discovered  in  the 
matters  vomited  by  these  patients.  As  a  matter  of 
course,  in  all  cases  of  nervous  vomiting  depending  on  a 
<:lefinite  lesion,  the  symptoms  of  the  latter  will  become 
prominent  from  time  to  time. 

Diagnosis.  This  is  liable  to  be  very  difficult,  and 
■especially  when  no  obvious  cause  for  the  symptom  can 
be  detected.  Vomiting  may,  however,  be  assigned  to 
nervous  causes  rather  than  to  any  organic  gastric 
mischief  when  the  appetite  is  good,  the  tongue  clean. 


S66  TREATMENT  OF  NERVOUS  VOMITING. 

the  general  appearance  that  of  fair  healthy  and  especially 
when  evidences  of  disordered  gastric  digestion  and  of 
objective  lesions  are  not  discovered  after  careful  examina- 
tion. There  is,  however,  one  point  on  which  too  much 
stress  can  scarcely  be  laid,  viz.,  the  possibility  that  the 
symptom  may  be  due  to  cerebral  tumour  or  incipient 
Bright's  disease.  The  ophthalmoscope  should  be  used^ 
and  if  a  choked  disc  be  discovered  there  will  be  little 
doubt  as  to  the  cause  of  the  symptom,  while  the  detec- 
tion of  albumen  in  the  urine  will  yield  a  clue  of  great 
importance.  All  the  organs  of  the  body  should  be 
examined  as  carefully  as  possible.  The  prognosis,  of 
course,  depends  upon  the  cause  of  the  symptom. 

In  treating  a  case  of  nervous  vomiting,  the  discovery 
of  the  cause  is  all-important,  and  if  it  can  be  dealt 
with  satisfactorily  the  symptom  may  be  expected  to 
cease.  Means  may,  however,  be  required  to  check  the 
vomiting,  and  of  these  the  administration  of  ice  and  of 
various  anodynes  is  the  most  efficacious.  The  patient 
should  be  kept  quiet  in  bed  and  should  be  allowed  to- 
suck  small  pieces  of  ice,  and  a  little  brandy  or  cham- 
pagne may  be  at  the  same  time  administered.  The 
morphine  is  best  used  hypodermically  (about  gr.  J),  and 
if  it  be   known  to   disagree,  a  dose  of  chloral  hydrate 


TREATMENT  OF  NERVOUS  VOMITING.  567 

internally  may  be  substituted  for  it.  Cocaine  would  be 
likely  to  relieve  this  kind  of  vomiting;  it  should  be 
administered  in  doses  of  gr.  \-\  and  repeated  according 
to  circumstances.  Hysterical  patients  will  probably  be 
relieved  by  a  few  drops  of  aether,  or  by  the  ammoniated 
tincture  of  valerian  in  doses  of  n^xv-xxx  on  a  lump  of 
sugar.  Bromide  of  potassium  is  sometimes  serviceable  ; 
it  may  be  combined  with  a  little  chloral.  If  collapse 
supervene  as  the  result  of  an  attack,  sether  may  be 
injected  subcutaneously,  or  beef-tea  and  brandy  given 
as  an  enema.  During  the  intervals  between  the  attacks 
a  course  of  bismuth  with  bicarbonate  of  sodium  and 
hydrocyanic  acid,  in  infusion  of  quassia  or  calumba,  will 
tend  to  prevent  recurrences.  The  patient  should,  of 
course,  be  careful  as  to  diet ;  distension  of  the  stomach 
should  be  avoided  and  the  food  should  be  of  an  easily 
digestible,  nourishing  character.  Whenever  flatulence 
is  a  prominent  symptom,  starchy  articles  of  food  must 
be  forbidden.  A  little  stimulant  should  be  taken  with 
meals,  old  whisky  or  brandy  being  the  most  suitable, 
and  either  of  these  may  be  advantageously  diluted  with 
seltzer  or  other  alkaline  effervescing  water.  For  the 
vomiting  of  pregnancy  oxalate  of  cerium  in  doses  of 
gr.  j-ij  is  often  serviceable. 


S68  NJERVOUS  ERUCTATIONS. 

In  connection  with  the  subject  of  nervous  vomiting, 
the  occurrence  of  frequent  eructations  due  presumably 
to  nervous  causes  requires  a  brief  notice.  Such  eructa- 
tions are  not  unfrequent  in  the  subjects  of  hysteria,  neu- 
rasthenia, and  hypochondriasis,  and  there  are  generally 
more  or  less  marked  indications  of  other  nervous  disorder, 
but  sometimes  the  eructations  are  so  frequent  and 
troublesome  as  to  constitute  the  principal  cause  of  the 
patient^s  suft'ering.  There  is  some  risk  lest  they  should 
be  attributed  to  the  presence  of  organic  disease  in  the 
stomach,  some  forms  of  which  are  accompanied  by 
eructations  as  a  symptom. 

In  cases  belonging  to  the  category  under  discussion, 
the  patient  is  worried  by  constant  or  frequent  eructations 
of  odourless,  tasteless  gas;  the  attacks  come  on  spon-. 
taneously,  but  they  are  very  liable  to  be  induced  by  any 
form  of  excitement.  In  some  patients  slight  pressure 
over  the  abdomen  or  on  the  spine  is  sufficient  to  cause 
eructations,  and  these  under  any  circumstances  may  go  on 
for  some  minutes  or  even  for  hours,  with  short  intervals 
between  them.  A  day  or  two  may  pass  during  which 
the  patient  is  comparatively  free,  and  these  are  followed 
by  hours  or  days  of  almost  continuous  discomfort.  The 
eructations  are   seldom   attended  by  any  decided  pain. 


NERVOUS  ERUCTATIONS.  569 

but  sometimes  a  feeling  of  constriction  is  mentioned; 
the  stomach  mav  appear  to  be  distended,  but  this  is  by 
no  means  always  the  case  even  when  the  eructations 
are  very  troublesome.  As  to  the  source  of  the  enormous 
<]uantities  of  gas  which  are  discharged,  possibly  much 
of  it  is  simply  air  that  has  been  swallowed;  the 
fermentation  of  food  might  account  for  some,  and  it  is 
not  improbable  that  gases  may  be  secreted  by  the 
stomach,  or  at  all  events  escape  from  the  vessels  in  their 
atonic  condition.  Analyses  have,  however,  shown  that 
the  gas  consists  mostly  of  atmospheric  air. 

A  case  presenting  many  of  the  features  just  described 
has  been  recently  reported  to  me  by  a  medical  friend. 
The  patient,  a  gentleman  aged  76,  had  for  many  years 
been  engaged  in  active  religious  controversy,  which  had 
left  its  mark  upon  him.  He  had  a  worn,  tired  look, 
was  subject  to  fits  of  depression  and  of  irritation,  and 
althou2;h  hio-hlv  intellis^ent,  was  unable  to  take  much 
interest  in  anything.  Even  reading  excited  him,  and 
time  hung;  heavily  on  his  hands.  He  had  a  fair  amount 
of  bodily  strength,  and  in  ordinary  weather  could  take 
sufficient  exercise.  For  some  two  or  three  years  before 
he  came  under  my  friend's  care  he  had  been  troubled 
with  frequent  gaseous  eructation,  not  connected  with  the 


570  NERVOUS  ERUCTATIONS. 


presence  of  food  in  the  stomachy  bat  always  made  worse 
by  the  least  excitement.  The  attacks  would  sometimes 
go  on  for  hours,  and  at  night  especially  they  were  apt  to  be 
very  troublesome,  preventing  sleep  and  causing  great 
irritation.  The  appetite  was  good  and  the  diet  had  always 
been  carefully  attended  to;  the  bowels  acted  regularly ; 
the  urine  was  pale,  normal  in  quantity,  of  somewhat 
low  specific  gravity,  but  contained  neither  albumen  nor 
sugar.  The  patient  was  a  tall,  thin  man,  of  decidedly 
nervous  temperament.  The  tongue  was  clean  and 
rather  large  and  flabby;  the  stomach  was  sometimes 
distended,  though  never  very  prominent.  After  repeated 
examinations  by  my  friend,  aided  by  a  distinguished 
London  physician,  nothing  abnormal  was  discoverable 
in  the  abdomen  or  elsewhere.  Various  medicines  and 
local  applications  gave  only  temporary  relief;  the 
patient  grew  thinner  and  more  miserable,  and  finally 
went  to  another  part  of  the  country,  where  he  died 
shortly  afterwards. 

The  treatment  of  such  a  case  as  that  above  described 
is  difficult  and  unsatisfactory.  The  patient  was  pro- 
vided with  a  set  of  artificial  teeth,  which  soon  became 
quite  comfortable  to  him.  Some  relief  was  obtained 
from  nux  vomica  and  small  doses  of  rhubarb,  and  fronii 


JS^ERVOUS  ERUCTATIONS.  571 

mustard  plaisters  over  the  stomach.  Small  closes  of 
creasote  and  of  carbolic  acid  were  tried,  combined  with 
morphine  and  myrrh,  and  at  first  the  discharge  of  gas 
was  appreciably  lessened,  but  the  improvement  was  not 
permanent.  Quinine,  too,  had  a  good  effect  for  a  time. 
Faradism  was  tried,  one  pole  being  placed  over  each 
extremity  of  the  stomach,  but  little  or  no  benefit 
resulted.  The  diet  received  the  most  careful  attention ; 
but  the  discomfort  appeared  to  be  unconnected  with  the 
food. 


CHAPTER  VI. 

ENTERALGIA— COLIC— NEURALGIA  MESENTERICA. 


Colic,  Definition  and  Causes — Irritating  Articles  of  Food — 
Gaseous  Distension  of  the  Abdomen — Drastic  Purgatives — 
Lead  and  Copper — Colic  as  a  Symptom  of  Nervous  Dis- 
orders, and  in  Connection  with  Gout  and  Rheumatism — 
Colic  due  to  Cold — Symptoms  of  Colic — Diagnosis — Pro- 
gnosis— Other  Forms  of  Colic — Neuralgia  of  the  Bowels — 
Nervous  Diarrhcea — Treatment — Aromatics  and  Stimulants 
— Warmth  Locally  —  Opiates — Ipecacuanha —  Purgatives  — 
Enemata — Morphine  Hypodermically — Treatment  of  Gouty 
and  Rheumatic  Cases —  Treatment  of  Neuralgia  of  the 
Bowels — Anodynes,  Tonics,  Improvement  of  General  Health, 
etc. 


Colic  may  be  defined  as  pain  in  the  intestines,  unat- 
tended by  obvious  anatomical  changes  in  any  of  the 
structures  of  the  bowels.  It  may,  therefore,  be  regarded 
as  a  purely  nervous  disorder,  sometimes  excited  by  the 
intestinal  contents,  or  by  changes  which  they  have 
undergone,  but  sometimes  occurring  as  an  independent 
neurosis.  In  cases  belonging  to  this  latter  category, 
either  central  or  reflex  peripheral  irritation  may  be 
presumed  to  exist. 

With  regard  to  the  intestinal  contents^  faecal  accumu- 


CA  USES  OF  ENTER  A  LGIA.  573 

lation  is  one  of  the  most  common  and  potent  causes 
of  colic.  Such  accumulation  acts  for  the  most  part  as 
a  mechanical  irritant  upon  the  mucous  membrane ;  the 
increasing  hardness  of  the  faeces  adds  to  the  effect  of 
their  volume^  by  which  the  bowel  is  abnormally  dis- 
tended. Less  common  causes  of  this  nature  are 
foreign  bodies  of  various  kinds,  e.g.,  masses  of  round 
worms,  or  of  tape-worms,  gall-stones,  and  foreign 
bodies,  swallowed  either  by  accident  or  intention. 
Severe  attacks  of  colic  are  often  caused  by  articles 
of  food  of  an  irritating  nature_,  or  having  acquired 
such  properties  after  having  been  swallowed.  Imper- 
fectlv  fermented  liquor  of  all  kinds,  unripe  fruit,  sour 
milk,  semi-decomposed  fish  or  meat  are  well-known 
causes  of  this  character.  I  have  seen  many  cases  of 
colic  due  to  irritating  ingesta  and  fascal  accumulation, 
and  two  instances  in  which  the  attacks  were  due  to 
tapeworms.  Even  normal  articles  of  food  may  serve  as 
irritants,  when  taken  in  excessive  quantities;  the  gastric 
and  intestinal  secretions  are  insufficient  for  their  due 
preparation  and  digestion,  and  more  or  less  decomposi- 
tion is  the  result.  In  another  class  of  cases,  the  attacks 
are  induced  by  the  physical  peculiarities  of  the  articles 
taken;  the  effect  upon  many  persons  of  cold  drinks  and 


S  74  CA  USE S  OF  ENTERAL  GIA . 

ices  may  be  quoted  as  an  example,  and  other  attacks 
are  connected  with  personal  idiosyncrasy.  Thus  in 
some  subjects  attacks  of  colic  are  apt  to  be  induced  by 
eating  certain  shell-fish_,  pork,  fruits  and  vegetables  of 
various  kinds,  all  of  which  other  persons  take  with 
complete  immunity. 

A  very  common  form  of  colic  is  that  which  is  due  to 
gaseous  distension  of  the  abdomen,  a  frequent  result  of 
the  fermentation  of  food.  This  form  is  very  often  seen 
in  children,  farinaceous  food  being  especially  liable  to 
undergo  fermentative  changes.  The  abuse  of  drastic 
purgative  medicines  is  another  cause  of  colic ;  instances 
of  this  character  are  common  among  poor  people. 
Cases  of  colic  due  to  the  influence  of  lead  and  copper 
form  a  distinct  class;  the  manner  in  which  these 
poisons  produce  their  effects  is  very  uncertain. 

As  a  neurosis,  in  the  strict  sense  of  the  term,  colic 
is  a  somewhat  common  complaint  among  the  subjects 
of  hysteria,  hypochondriasis,  and  neurasthenia,  and  it 
likewise  occurs  in  connection  with  some  organic  dis- 
orders of  the  nervous  system.  Thus  the  gastric  crises 
of  locomotor  ataxy  are  sometimes  accompanied  by  like 
symptoms  referable  to  the  intestines.  Such  enteric 
crises  may,  however,  occur  independently;  they  take  the 


SYMPTOMS  OF  JENTERALGIA.  575 

form  of  sudden  attacks  of  diarrhoea,  with  or  without 
pain,  and  they  may  continue  for  several  days.  As 
examples  of  colic  due  to  reflex  action  may  be  mentioned 
the  intestinal  pain  and  diarrhoea  which  sometimes 
accompanies  disorders  of  the  liver,  kidneys,  uterus,  and 
ovaries. 

Both  the  gouty  and  the  rheumatic  diatheses  occasion- 
ally contribute  towards  the  production  of  an  attack  of 
colic.  In  gouty  cases  the  symptom  may  precede  the 
articular  inflammation  and  subside  on  its  development, 
or  may  replace  it,  little  or  no  pain  being  felt  in  the 
joint.  In  colic  connected  with  gout  and  rheumatism^ 
there  is  often  tenderness  on  pressure_,  and  sometimes 
fever.  Pain  in  the  intestines  of  a  ^leuralgic  character 
and  coming  on  at  regular  intervals,  has  been  occasion- 
ally observed  in  cases  of  malarious  fever.  The  only 
other  important  cause  of  colic  Vv'hich  requires  notice  is 
exposure  to  cold  and  wet.  Cases  of  this  kind  are 
somewhat  frequent;  contraction  of  the  cutaneous  vessels 
may  be  supposed  to  be  followed  by  dilatation  of  the 
intestinal  capillaries.  Cold  applied  directly  to  the 
abdomen  may  produce  an  immediate  effect  on  the 
muscular  coat  of  the  intestines. 

The  principal  symptom    in    colic  is  the  pain  which 


576  SYMPTOMS  OF  ENTERALGIA. 

comes  on  suddenly  without  premonitory  warnings^  anc! 
is  felt  especially  in  and  about  the  umbilicus^  whence  it 
extends  to  the  region  of  the  caecum,  ascending  and 
transverse  colon;  but  it  often  radiates  to  the  loins,  and 
downwards  towards  the  thighs.  The  severest  pain  is 
sometimes  confined  to  one  spot ;  in  other  cases  the  pain 
changes  its  place  and  is  then  often  accompanied  by- 
rumbling  noises  in  the  intestines,  portions  of  which 
create  protrusions  from  the  abdominal  wall.  As"  a 
general  rule  the  pain  is  at  first  slight,  and  gradually 
increases  in  intensity,  but  in  some  cases  it  is  very  severe 
from  the  first.  Like  other  kinds  of  pain,  the  sensation 
is  variously  described  by  different  patients  ;  thus,  it  is 
sometimes  said  to  be  cutting,  pricking,  pinching,  boring, 
or  as  though  the  bowel  were  being  stretched  or  torn. 
The  violence  of  the  pain  may  be  such  that  persons  with 
considerable  command  over  themselves  are  completely 
overcome  by  it,  and  are  unable  to  check  their  cries  and 
groans.  As  objective  symptoms,  the  skin  becomes  cool 
and  covered  with  perspiration  ;  the  face  is  pale,  the 
pulse  is  generally  slow  and  hard.  The  attacks  vary 
considerably  as  regards  duration  and  liability  to  recur- 
rence; sometimes  the  pain  ceases  after  a  few  minutes, 
and  does  not  return  ;  in  other  cases  the  attacks  recur 


SYMPTOMS  OF  ENTERAL  GIA.  577 

again  and  again  during  several  liours,  and  the  patient  is 
never  entirely  free  from  ]iain  during  that  time. 

The  positions  assumed  by  patients  suffering  from 
colic  are  often  characteristic  ;  the  sufferer  lies  ^'doubled 
up/'  as  it  is  termed^  with  the  knees  brought  close  to 
the  abdomen^  or  he  presses  his  bands  against  the  painful 
part  and  sometimes  he  tries  to  get  ease  by  adopting  a 
prone  position.  On  examining  the  abdomen,  it  is  either 
hard  and  retracted,  or  prominent,  tympanitic  and  dis- 
tended. In  a  thin  patient,  the  distended  loops  of 
intestine  are  often  plainly  visible,  and  the  irregular 
peristaltic  movements  can  be  easily  traced.  Rumblino; 
sounds — borborygmi — are  often  associated  with  the 
movements. 

In  most  cases  of  colic,  the  pain  is  relieved  by  firm 
pressure  over  the  abdomen,  and  the  patient's  experience 
teaches  him  to  try  this  plan.  In  some  cases,  however, 
there  is  decided  tenderness  of  the  abdomen,  and  pressure 
causes  so  much  pain  as  to  give  rise  to  the  suspicion  of 
.peritonitis.  Symptoms  due  to  reflex  action  are  fre- 
quently experienced  in  other  organs;  thus,  attacks  of 
colic  are  liable  to  be  attended  with  nausea  and  vomitino- 
hiccough,  dyspnoea,  palpitation  of  the  heart,  precordial 
oppression,  strangury,  tenesmus,  etc.     In  male  subjects 

37 


578  BIAGHrOSIS  OF  JENTUBALGIA. 

the  testicles  are  often  drawn  up  and  the  levator  ani  is 
spasmodically  contracted.  Painful  cramps  in  the  legs,, 
fainting,  and  other  symptoms  of  collapse,  muscular 
twitchingSj  and  even  convulsions  have  been  noticed  in 
some  cases. 

As  a  general  rule,  after  lasting  for  a  variable  time, 
attacks  of  colic  suddenly  pass  off,  perhaps  after  vomit- 
ing, eructations,  discharge  of  flatus  or  diarrhoea.  Com- 
plete recovery  is  the  rale,  but  death  has  been  known  to 
occur,  as  a  result  of  rupture  of  the  intestines  from 
excessive  gaseous  distension ;  and  in  another  case  the 
fatal  issue  was  due  to  convulsions. 

The  diagnosis  of  colic  is  for  the  most  part  easily  made 
provided  that  the  case  be  carefully  investigated.  The 
important  point  to  determine  is  whether  the  symptoms 
are  due  to  some  organic  lesion,  inflammatory  or  other- 
wise, or  whether  this  possibility  can  be  excluded.  Colic 
in  hvsterical  subjects  may  be  so  severe  as  to  resemble 
peritonitis,  but  it  differs  essentially  from  the  latter  in 
being  unattended  by  fever,  and  as  a  general  rule,  by 
tenderness,  either  on  gentle  or  firm  pressure.  More- 
over, in  peritonitis,  the  symptoms  are  continuous,  and 
rend  to  become  worse.  It  must,  of  course,  be  remem- 
bered  that    colicky  pains    are  apt  to   occur    in   many 


DIAGNOSIS  OF  JENTERALGIA.  579 

intestinal  affections,,  and  especially  in  dysentery,  and 
in  connection  with  catarrhal^  tuberculous  and  carcino- 
matous ulceration.  It  would  scarcely  be  possible, 
however^  to  mistake  the  symptoms  of  these  diseases 
for  an  attack  of  colic,  and  the  same  remark  applies  to 
strangulated  hernia,  which  cannot  be  overlooked  on 
proper  examination. 

Rheumatism  of  the  abdominal  muscles  may  be  mis- 
taken for  colic,  but  in  the  former  the  pain  shifts   its 
place,  is  apt  to  become  chronic,  and  exhibits  no  decided 
exacerbations  and  remissions.     The  abdomen  is  tender 
to  the  touch,  the  pain  is  not  deep-seated,  but   super- 
ficial,   and    can    be    excited    by    friction.       In    lumbo- 
abdominal  neuralgia  points  douloureux  can  generally  be 
detected    towards    the    vertebral    column.       Hysterical 
subjects  are  liable  to  colic,  and  likewise  to   neuralgic 
pains   in  the  abdominal   muscles   and   skin,  of  a  shift- 
ing character,  and  generally  relieved    by    friction   with 
anodyne  liniments.     As   a  matter  of  course,   when  a 
diagnosis  of  colic  has  been  arrived  at,  the  nature  of  the 
attack  has  yet  to  be  determined,  and  for  this  purpose  it 
would    be    necessary   to    take    into    consideration    the 
various  points  discussed   in  the  aetiology.     The  possi- 
bility of  lead   being  the  cause  of  colic   must  never  be 


,580  VARIOUS  FOEMS  OF  ENTJSRALGIA. 

forgotten ;  the  gams  should  always  be  examined  for  any 
traces  of  a  blue  line.  I  have  seen  several  cases  of  in- 
tractable colic  due  to  lead  speedily  relieved  after  dis- 
covery of  the  causCj  which  had  not  been  previously 
suspected. 

The  prognosis  in  cases  of  colic  depends  upon  the 
cause  of  the  symptom ;  in  the  great  majority  of  cases 
the  complaint  yields  readily  to  suitable  treatment. 
When  the  pain  is  dependent  upon  obstruction  in  the 
bowels  and  persists  in  spite  of  remedies,  the  prognosis 
must  be  more  guarded.  Unless,  however^  the  obstacle 
be  insuperable,  as  in  cases  of  malignant  disease  of 
the  bowel,  recovery  may  be  expected  to  take  place. 
Neglected  attacks  of  colic  may  pass  into  actual  inflam- 
mation, either  of  the  peritoneal  or  of  the  mucous  coat 
of  the  bowel. 

Before  proceeding  to  discuss  the  treatment,  it  will  be 
well  to  refer  to  certain  modifications  sometimes  notice- 
able in  the  symptoms  of  these  painful  aflections  of 
the  bowels.  Cases  are  met  with  from  time  to  time 
in  which  the  spasmodic  element  is  either  wantmg 
altogether,  or  else  very  slightly  marked,  though  the 
pain  is  very  severe  indeed.  There  is  no  inflammation 
and    no    attendant   vascular  excitement,  and  the  pain. 


VARIOUS  FORMS  OF  FNTFRALGIA.  581 

though  paroxysmal^  is  more  steady  for  some  time  than 
in  spasmodic  colic.  The  paroxysms  are  wont  to  occur 
without  obvious  cause,  though  they  are  sometimes 
excited  by  the  passage  of  food;  some  amount  of  tender- 
ness often  remains  after  their  subsidence.  These 
attacks,  to  which  the  term  ^'  neuralgia  of  the  bowel  " 
would  appear  to  be  applicable^,  are  due  to  various 
causes,,  such  as  general  debility,  a  rheumatic  or 
gouty  diathesis,  spinal  disorder,  or  some  affection  of  the 
sympathetic  ganglia.  Dr.  Clifford  Allbutt  thinks  that 
gout  and  the  strife  of  public  life  are  potent  factors  in 
the  production  of  enteralgia ;  he  has  given  details  of 
several  cases  in  his  lectures  on  "  Visceral  Neuroses;  " 
my  own  experience  coincides  with  this  author's  views. 
After  severe  attacks,  the  collapse  and  prostration  are 
often  very  serious;  periodicity  is  sometimes  noticeable; 
and  in  some  cases  the  enteralgia  takes  the  place  of 
another  neurosis,  e.g.,  migraine.  There  is  no  marked 
constipation,  flatulence  or  disordered  alvine  secretions, 
and  the  complaint  is  associated  with  various  conditions 
of  the  general  health. 

Disordered  innervation  of  the  intestinal  tract  mav 
produce  disturbances  not  only  of  sensation,  but  also  of 
motion  and  secretion,  and  according  as  the  motor  activity 


582  TREA  TMENT  OF  ENTER  A  LGIA. 

is  lessened  or  excited,  symptoms  either  of  nervous 
constipation  or  of  nervous  diarrhoea  will  be  liable  to 
occur.  In  many  persons,  attacks  of  the  latter  complaint 
are  liable  to  be  induced  by  anxiety  or  grief;  in  others, 
the  subjects  of  idiosyncrasies,  such  attacks  set  in 
immediately  after  certain  articles  of  food  have  been 
taken,  and  are  to  be  explained  by  attributing  them  to 
increased  peristaltic  action  the  result  of  nerve-irritation. 
The  intestines  often  participate  in  disordered  action  of 
the  stomach ;  and  symptoms  referable  to  both  these 
parts  iare  frequent  in  cases  of  hysteria,  hypochondriasis, 
and  neurasthenia,  and  in  women  suffering  from  ovarian 
and  uterine  disorders.  In  the  treatment  of  these  nervous 
gastric  and  intestinal  troubles  it  is  of  great  importance 
to  bear  in  mind  the  condition  which  underlies  all  the 
manifestations. 

In  treating  a  case  of  colic  the  cause  of  the  attack  is 
the  first  point  to  be  attended  to ;  relief  of  the  pain  and 
evacuation  of  the  bowels  are  the  main  indications.  For 
simple  spasmodic  colic,  due  to  flatulence  or  exposure  to 
cold,  and  of  no  great  severity,  relief  may  often  be  obtained 
by  the  exhibition  of  aromatics  and  stimulants,  such  as 
tincture  of  ginger,  spirits  of  peppermint,  compound 
tincture    of  lavender   or    cardamoms    diluted  with   hot 


TREATMENT  OF  ENTERALGIA. 


water.  To  any  of  these  a  few  drops  of  laudanum  or 
half  a  drachm  of  compound  tincture  of  camphor  may 
be  added  to  relieve  pain^  or  tincture  of  chloroform  and 
morphine  nt  x  mav  be  given  for  the  same  purpose.  At 
the  same  time  warm  applications,  e.g.,  turpentine 
stupes,  to  the  abdomen  and  placing  the  feet  in  warm 
water  will  aid  in  procuring  relief.  In  hysterical  cases 
some  tincture  of  asafoetida  or  valerian  may  be  combined 
with  the  aromatics.  Sev^ere  pain  must  be  checked  bv 
increased  doses  of  opiates^  and  if  symptoms  of  collapse 
set  in,  «ther  and  other  stimulants  may  be  freely  given. 
When  the  attack  of  colic  is  obviously  due  to  acrid 
and  irritating  ingesta,  antispasmodics  and  opiates  must 
be  withheld  until  the  source  of  the  evil  has  been  got 
rid  of.  If  the  attack  commence  soon  after  eating,  it 
will  be  well  to  administer  an  emetic,  and  ipecacuanha 
will  be  the  most  suitable,  inasmuch  as  it  often  produces 
free  action  of  the  bowels.  When  the  stomach  has 
been  evacuated,  five  grains  of  calomel  or  a  draught  con- 
taining rhubarb,  soda,  and  aromatic  spirit  of  ammonia 
may  be  given  if  the  bowels  have  not  been  sufficiently 
relieved.  To  hasten  the  action  of  the  cathartics,  and 
as  substitutes  for  them  when  the  transverse  colon  is  the 
principal  seat    of   pain,    purgative  enemata  are  of   the 


584  TREATMJENT  OF  JENTERALGIA. 

greatest  service.  Warm  water,  injected  slowly  with  an 
O'Beirne's  tube,  may  prove  sufficient,  but  if  not,  a 
turpentine  enema  may  be  employed.  In  hysterical 
cases,  and  especially  if  there  be  much  flatulence,  a 
warm  water  enema  containing  a  drachm  of  asafoetida 
will  be  preferable.  If  convulsions  occur,  chloroform 
inhalation  (not  pushed  to  complete  anaesthesia)  will 
check  the  movements,  and  likewise  subdue  the  intestinal 
spasm.  For  the  relief  of  the  latter,  and  especially  in 
dealing  with  children,  a  warm  bath  will  prove  very 
efficient. 

In  all  these  cases  of  colic,  after  the  pain  and  spasm 
have  subsided  and  the  bowels  have  been  thoroughly 
evacuated,  the  patient  should  be  kept  quiet  and  warm 
for  some  time.  The  diet  should  be  carefully  regulated ; 
food  of  a  light  and  easily  digestible  nature  should  be 
prescribed,  and  everything  likely  to  engender  flatulence 
must  be  rigorously  interdicted.  If  necessary  the 
bowels  must  be  kept  open  by  mild  laxatives,  and 
aromatics,  with  bitter  tonics,  may  be  given  to  prevent 
recurrences. 

If  the  colic  be  suspected  to  be  due  to  the  presence 
of  worms,  or  other  foreign  bodies,  the  treatment  is 
obvious.     For  tapeworm,  the  oil  of  male  fern  or  the  oil 


TREATMENT  OF  ENTERALGIA.  585 

of  turpentine  should  be  given  in  suitable  doses.     When 
the  attack  is  due  to  irritating  articles  of  food^  and  has 
come  on  some  hours  after  they  have  been  taken,  or  to 
distension,  the  result  of  fermentation,  v^e  may  give  such 
purgatives  as  above  described,  or  a  dose  of  castor  oil  if 
tolerated  by  the  stomach ;  and  in  any  of  these  cases  if 
the   pain    be   very   severe,    we   may  at  the  same  time 
endeavour  to  subdue  it  by  administering  opium  in  some 
form.     The   hypodermic   injection  of    morphine  gr.    J 
will  be  found  very  suitable,  and   its   effects,  as   regards 
both  pain  and  spasm,  will  be  increased  by  adding  gr. 
-^Q  of  atropine.     Laudanum   may  also  be  added  to  the 
castor  oil   and    to    the    rhubarb    draught.      When  the 
attack   is   due   to    the    abuse    of   purgative  medicines, 
opium  is  especially  indicated,  and  it  may  be  advantage- 
ously combined  with  chalk  and  aromatics. 

In  attacks  of  colic  of  gouty  or  rheumatic  origin  it  is 
generally  desirable  to  evacuate  the  bowels,  and  for  this 
purpose  the  draught  containing  rhubarb,  soda,  magnesia, 
•and  tincture  of  cardamoms  will  be  found  most  service- 
able. Local  external  remedies,  and  the  use  of  the  warm 
or  hot  bath,  are  desirable  adjuvants.  In  gouty  subjects, 
if  the  attack  be  due  to  metastasis,  revulsion  to  the 
extremities    is  indicated,   for  which   purpose   hot   and 


8  6  TREA  TMENT  OF  ENTERAL  GIA . 


Stimulating  foot-baths^  with  sinapisms  to  the  feet  and 
ankles  may  be  employed.  After  the  acute  pain  has 
subsided^  a  draught  containing  tinct.  colchici,  liquor, 
morphinse  hydrochlorat.,  aa  nixv,  may  be  given  every 
four  hours  for  a  day  or  two^  in  order  to  diminish  irrita- 
tion. Under  similar  circumstances,  in  rheumatic  cases^ 
bromide  of  potassium  with  alkalies  and  some  bitter 
tonic  should  be  administered,  the  diet  in  all  these  cases 
being  very  carefully  attended  to. 

In  that  form  of  colic  which  is  attributable  to  neuralgia 
of  the  bo\vels_,  purgatives  and  other  remedies  of  a 
lowering  character  are  seldom  indicated;  on  the  other 
hand,  anodynes  and  tonics  constitute  the  best  remedies 
for  the  symptoms.  Morphine  may  be  administered 
subcutaneously  in  combination  with  atropine ;  and  if  the 
former  drug  be  ill  borne,  atropine  alone  or  the  extracts 
of  belladonna,  conium,  or  hyoscyamus  may  be  given 
separately  or  in  combination,  and  pushed  so  far  as  to 
produce  a  decided  effect.  Preparations  of  iron,  especially 
the  carbonate,  are  likely  to  prove  serviceable,  and  if 
there  be  any  evidence  of  periodicity,  quinine  should  be 
administered  in  combination  with  hydrobromic  acid. 
The  diet  requires  careful  attention  ;  it  should  be  of  a 
nutritious    character    and    abundant    in    quantity.      In 


TREA  TMENT  OF  ENTER  A  L  GIA.  587 

extreme  cases,  the  Weir-Mitchell  system  of  treatment 
should  be  tried,  or  at  least  the  patient  shoidd  be  kept  in 
bed  for  two  or  three  weeks  ;  warmth  is  always  beneficial. 
Change  of  air_,  rest_,  freedom  from  worry,  and  cheerful 
society  will  tend  to  cure  the  complaint,  and  to  prevent 
recurrences.  When  pain  in  the  stomach  is  associated 
with  the  abdominal  symptoms,  small  doses  of  arsenic 
taken  after  meals  will  be  found  very  efficacious.  The 
treatment  of  nervous  diarrhoea,  due  to  disordered  motor 
activity,  will  be  discussed  in  a  subsequent  chapter. 


CHAPTER  VII. 

CONSTIPATION. 


Prevaience  of  Constipation — Causes,  Age,  Sex,  Occupation, 
Want  of  Exercise,  Neglect — Too  little  Fluid  in  Diet — 
Normal  Action  of  Bowels — Contents  of  Fjeces — Def^ecation 
— Consequences  of  Constipation — Chlorosis — Other  Causes 
of  Constipation  and  Disorders  with  which  Associated — 
Surgical  Causes  —  Habitual  Constipation,  Influence  of 
Drastic  Purgatives — Insufficiency  and  Improper  Quality 
of  Food — Diagnosis — Treatment  of  Constipation — Of  Occa- 
sional Attacks — Castor  Oil,  Salines,  Rhubarb,  Calomel  and 
Senna — Enemata — Faradism — Treatment  of  Chronic  Consti- 
pation— Attention  to  Habits — Necessity  of  Daily  Visit  to 
the  Closet — Regulation  of  Diet — Fruits  and  Vegetables, 
Fluids — Laxatives,  Aloes  and  Cascara — Castor  Oil,  Senna, 
AND  Bitter  Tonics — Nux  Vomica — Salines,  Mineral  Waters, 
Friedrichshall,  Rubinat-Condal,  Etc.  —  Carlsbad  Salts — 
Hepatic   Stimulants   as  Podophyllin,  Iridin,  Euonymin,  and 

LepTANDRIN NiTRO-MURIATIC    AciD BELLADONNA EneMATA, 

their  Drawbacks — Other   Remedies — Caution   as  to  Use   of 
Laxatives. 


Of  the  functional  disorders  of  daily  life_,  few  are  more 
common  than  constipation.  It  affects  persons  of  all 
ages  and  both  sexes,  though  women,  and  especially 
married  women  who  have  borne  children,  are  particu- 
larly liable  to  be  troubled.  It  is  a  common  ailment  of 
scrofulous,  rachitic,  and  syphilitic  children,  and  also  of 


CAUSES  OF  CONSTIPATION.  589 

infants  brought  up  by  hand.  It  likewise  constitutes 
one  of  the  difficulties  connected  with  advanced  age. 
Examples  of  the  complaint  are  to  be  found  in  every 
class,  but  certain  occupations  and  habits  specially 
favour  its  development.  Thus  the  effect  of  lead  in  the 
production  of  constipation  is  well  known^  and  we  find 
that  persons  who  lead  sedentary,  lives,  e.g.,  tailors^ 
shoemakers_,  seamstresses^  lawyers^  and  intellectual 
workers  in  general,  form  a  large  contingent  of  cases. 
On  the  other  hand,  labourers  are  seldom  affected,  for 
bodily  exercise  stimulates  peristaltic  action,  increases 
respiration  and  circulation,  and  improves  the  quality  of 
the  blood,  while  the  action  of  the  diaphragm  and 
abdominal  muscles  on  the  intestines  produces  an  effect 
similar  to  that  of  massage. 

Constipation  is  frequently  experienced  by  those  who 
lead  luxurious  and  slothful  lives,  who  eat,  drink,  and 
smoke  too  much,  who  are  irregular  at  their  meals  and 
indulge  in  various  enervating  habits.  The  complaint  is 
also  common  among  persons  in  many  respects  just  the,, 
opposite  to  those  just  described.  Men  actively  employed 
in  business,  having  apparently  more  to  do  than  time 
will  permit,  often  hurrying  over  their  breakfasts  to  catch 
a  train,  are   very  apt  to    neglect    the    calls  of  nature. 


590  CAUSES  OF  CONSTIPATION. 

Women,  too,  frequently  suffer  from  similar  neglect,  and 
in  their  case  another  important  factor  often  comes  into 
play,  viz.,  an  insufficient  amount  of  fluid  in  their  diet. 
Water  forms  the  principal  constituent  of  the  body,  and 
the  integrity  of  its  various  parts  is  closely  connected 
with  the  amount  of  fluid  contained  therein.  When  an 
insufficient  quantity  of  water  is  taken  the  excreta 
become  inspissated  and  hard,  and  pass  through  the 
bowels  with  difficulty.  As  a  result  of  their  retention 
the  sensitiveness  of  the  rectal  walls  becomes  deadened  ; 
the  sigmoid  flexure  and  the  colon  are  abnormally  dis- 
tended, the  muscular  coat  of  the  bowel  is  weakened, 
and  the  peristaltic  power  considerably  reduced,  and  in 
this  way  a  condition  of  chronic  constipation  is  slowly 
but  surely  established. 

For  perfect  health,  as  a  general  rule,  it  is  necessary 
that  the  bowels  should  be  relieved  once  in  34  hours. 
Owing  to  a  variety  of  causes,  some  persons  have  an 
action  of  the  bowels  once  in  two  or  three  days,  or  even 
at  a  longer  interval,  and  yet  enjoy  good  health  ;  while 
others,  again,  are  not  comfortable  unless  the  bowels  act 
twice  or  three  times  a  day.  There  are  infinite  differences 
with  regard  to  frequency  of  action;  Dr.  Habershon 
relates  the  case  of  a  woman,  60  years  of  age,  who  from 


CONTENTS  OF  FjECES. 


591 


her  youth  up  had  had  a  passage  only  every  six  or  eight 
days^  and  yet  was  always  healthy.  Variations  are  due 
to  individual  peculiarities  and  conditions^  such  as 
temperament,  quantity  and  quality  of  the  food ;  the 
rapidity  and  completeness  of  the  digestive  processes, 
whereby  there  is  a  smaller  or  larger  residue;  the  activity 
or  otherwise  of  the  skin  and  the  normal  average 
peristaltic  power  of  the  intestine. 

That  a  daily  action  of  the  bowels  is  most  conducive 
to  health  is  not  only  borne  out  by  experience  generally, 
but  is  also  confirmed  by  the  teachings  of  physiology. 
The  contents  of  the  large  intestine  are  made  up  of  the 
remains  of  food  that  has  resisted  the  digestive  pro- 
cesses in  the  passage  from  the  stomach  to  the  colon. 
These  differ  in  consistence,  colour,  and  odour,  and  in 
chemical  and  microscopical  appearances  from  the 
contents  of  the  small  intestine.  The  average  quantity 
in  24  hours  is  about  4^ozs.,  "j^  per  cent,  of  which  is 
water.  The  odour  is  due  to  decomposition  of  the 
residue  of  the  food  ;  the  colour  to  the  bile  pigment, 
the  absence  of  which  leaves  the  faeces  light  or  clay- 
coloured,  while  their  consistence  is  the  result  of  the 
constant  absorption  of  the  liquid  portions.  About 
10    per    cent,    of   the   solid    residue    consists    of    un- 


592  NORMAL  DEFECATION. 

digested  matters,  and  the  remainder  of  faecal  sub- 
stances. 

The  undigested  matters  examined  under  the  micro- 
scope are  found  to  be  composed  of  animal  and 
vegetable  structures  that  have  not  been  acted  upon  by 
the  digestive  fluids ;  the  faecal  substances  are  made  up 
of  disintegrated  intestinal  epithelium_,  mucus,  and  the 
solid  remains  of  the  secretions,  none  of  which  serve  to 
nourish  the  body.  As  the  faeces  are  moved  along  the 
large  intestine  by  its  peristaltic  power,  they  become 
more  solid  and  acid  in  reaction  -,  fermentation  is  often 
set  up  and  is  accompanied  by  the  development  of 
several  gases.  Owing  to  the  absorption  which  takes 
place  in  the  colon,  the  faeces  gradually  become  more 
solid,  till  the  sigmoid  flexure  is  reached.  Here  they 
rest  upon  the  bladder  and  sacrum,  but  do  not  press 
upon  the  sphincter  ani.  When  the  column  of  faeces 
descends  into  the  rectum,  peristaltic  action  is  excited  in 
its  walls,  so  that  the  mass  is  pressed  against  the 
sphincter;  the  lumbar  centre  which  controls  this 
muscle  is  now  inhibited,  the  abdominal  and  accessory 
muscles  come  into  play,  the  sphincter  is  relaxed,  and  the 
rectum  is  unloaded. 

The  maximum  irritation  of  the  rectal  walls  occurs, 


RESULTS   OF  CONSTIPATION.  593 


as  a  rule,  once  in  24  hours  ;  and  when  the  liabit  has 
become  regularlv  estabhshed,  the  desire  to  defaecate  at 
a  certain  hour  is  quite  independent  of  the  will. 

When  we  consider  the  niechanisin  of  defaecation_, 
the  composition  of  the  faeces^  the  effects  of  pressure 
upon  the  rectal  and  intestinal  walls,  an'd  the  local,  as 
well  as  the  general  symptoms  that  are  aroused  bv  the 
retention  of  faeces,  we  must  be  convinced  that  it  is  of 
the  greatest  importance  for  the  health  of  the  body  that 
the  act  should  be  regularlv  and  thoroughly  accom- 
plished. 

Apart  altogether  from  the  local  disturbances  that  are 
set  up  by  the  presence  of  retained  faeces,  there  is  risk 
of  a  kind  of  blood-poisoning  from  the  absorption  by 
the  colon  of  portions  of  the  fermenting  and  decompos- 
ing mass.  The  results,  as  often  witnessed,  are  pale- 
ness and  loss  of  flesh,  a  dull  and  unhealthy  complexion, 
and  offensive  exhalations  from  the  skin  and  lungs; 
dulness  and  depression  of  spirits,  irritability,  drowsi- 
ness, vertigo,  headache,  palpitation,  furred  tongue, 
pains  in  the  loins,  gastric  derangement,  and  various 
biliary  and  urinary  disorders.  Conditions  of  hypochon- 
driasis and  melancholia  are  often  traceable  to  constipa- 
tion. 

38 


594  CAUSJES  OF  CONSTIPATION. 

A  recent  writer  in  the  Lancet  (Nov.  26,  1887) 
regards  chlorosis  as  a  consequence  of  auto-infection,  a 
true  poisoning,  from  the  retention  of  fseculent  matters  in 
the  intestine.  The  affection  is  generally  preceded  and 
accompanied  by  constipation  :  sometimes  the  poisoning- 
takes  place  rapidly,  putrid  decomposition  being  promptly 
followed  by  absorption  from  the  intestine.  Febrile 
symptoms  are  another  result  of  auto-infection.  It  may 
be  doubted  whether  constipation  is  the  sole  cause  of 
chlorosis,  but  it  is  probably  an  important  factor  in  the 
production  of  the  complaint. 

There  is  often  constipation,  of  a  temporary  kind,  in 
acute  and  wasting  diseases,  such  as  acute  rheumatism, 
phthisis,  and  various  fevers.  Under  such  circumstances 
the  condition  is  due  mainly  to  the  dryness  of  the  intes- 
tinal contents  (inasmuch  as  more  water  escapes  through 
the  skin  and  lungs),  to  the  diminution  in  their  amount, 
and  likewise  to  the  change  of  habits  necessitated  by  the 
disorder.  Constipation  is  common  in  puerperal  women, 
owing  to  the  pressure  of  the  uterus  on  the  intestines,  to 
the  relaxation  of  the  abdominal  walls,  and  the  with- 
drawal of  fluid,  resulting  from  the  secretion  of  milk. 
The  constipation  that  so  often  accompanies  jaundice 
may  be  due    to    the    absence    of   bile,    which    excites 


CAUSES  OF  CONSTIPATION.  595 

peristaltic  action^  or  to  the  accumulation  of  that  secre- 
tion in  the  blood,  whereby  the  intestinal  movements  are 
hindered,  as  is  also  the  action  of  the  heart.  Constipa- 
tion is  always  pr'esent  in  acute  hydrocephalus,  and  is 
due  to  the  irritation  of  the  inhibitory  nerv^es.  The 
same  condition  likewise  prevails  in  acute  peritonitis,  and 
is  due  to  the  extension  of  th-e  inflammation  to  the 
muscular  coat  of  the  bowels.  The  walls  become  infil- 
trated with  serum,  and  thus  their  tonicity  and  peristaltic 
power  are  much  impaired. 

It  is  not  my  object,  however,  in  the  present  chapter 
to  consider  all  the  forms  of  constipation,  acute  and 
chronic,  wdiich  are  met  with  by  the  physician  in  daily 
practice,  or  to  discuss  minutely  all  the  various  causes 
that  may  produce  the  complaint.  I  propose  rather  to 
confine  my  remarks  to  the  more  common  forms  of 
habitual  constipation  due  to  deficient  propelling  power 
of  the  intestines,  and  not  dependent  upon  mechanical 
obstruction  in  these  organs  or  in  the  surroundino; 
tissues.  Causes  belono;ino;  to  the  cates^ories  last  men- 
tioned  must,  however^  be  referred  to  in  connection 
with  diagnosis,  and  though  little  more  than  their 
enumeration  can  be  attempted,  yet  in  order  to  arrive 
at  a  correct  estimate  of  the  nature  of  the  disorder    in 


596  CAUSES  OF  CONSTIPATION. 

any  given  case,  they  must  be  carefully  borne  in  mind  in 
the  examination  of  the  patient. 

In  general  terms  it  may  be  stated  that  anything 
that  retards  or  prevents  the  passage  of  the  faeces  through 
and  out  of  the  intestines  will  be  a  cause  of  constipa- 
tion. Obstruction,  slowly  developed,  may  be  due  to 
pressure  on  the  rectum  by  an  ovarian  or  uterine 
tumour;  to  displacements  of  the  uterus;  enlarged 
prostate;  polypoid  growths  in  the  rectum  or  colon; 
cancerous  or  other  stricture  of  the  rectum,  or  other 
portions  of  the  intestines.  Dysentery  and  syphilis  are 
the  most  common  causes  of  the  latter  character  :  their 
eflFects  are  slowly  produced,  and  the  condition  always 
tends  from  bad  to  worse. 

Constipation  is  also,  caused  by  internal  strangula- 
tion and  by  bands  formed  in  peritonitis.  Internal 
obstruction  may  be  caused  by  one  portion  of  intestine 
entering  another  (invagination)  or  passing  into  one 
of  the  foramina  connected  with  the  abdomen  ;  by  twist- 
ing of  the  mesentery,  or  of  this  structure  and  a  portion 
of  intestine  about  a  loop  of  the  latter;  and  finally  by 
rotation  of  the  intestine  upon  its  own  axis.  As  a 
result  of  chronic  diarrhoea,  the  lower  end  of  the  small 
intestine  sometimes  enters  the   colon,  and  prolapse  of 


SURGICAL   CAUSES  OF  CONSTIPATION.  597 


portions  of  the  latter  into  the  rectum  is  not  uncommon 
as  a  result  of  severe  and  chronic  dysentery. 

There  are  certain  surgical  disorders  which  produce 
constipation  and  require  a  hrief  notice.  Chief  among 
these  is  fissure  or  painful  ulcer  of  the  rectum  ;  in  this 
complaint  defaecation  is  accompanied  and  followed  by 
very  severe  pain.  A  similar  condition  is  sometimes 
noticed  in  connection  with  haemorrhoids,  the  mucous 
membrane  covering  them  becoming  ulcerated  and  exqui- 
sitely sore.  In  both  these  cases  constipation  is  largely 
due  to  the  efforts  of  the  patient  to  restrain  the  bowels 
from  acting  J  the  retained  faeces  increase  the  ulceration 
and  prevent  healing.  In  elderly  persons  degeneration  of 
the  muscular  tissue,  especially  of  the  rectum,  sometimes 
induces  constipation,  and  in  male  subjects  enlargement 
of  the  prostate  may  impede  defaecation  and  lead  to  the 
same  result.  After  injuries  of  various  kinds  requiring 
confinement  to  bed,  constipation  is  a  common  trouble, 
but  unless  other  conditions  be  present  it  generally 
subsides.  After  injuries  to  the  head  and  spine,  and  in 
many  chronic  nervous  affections,  the  bowels  are  apt  to 
become  much  confined,  and  the  original  disorder  is 
thereby  considerably  aggravated. 

Having  thus  glanced  at  some  of  the  structural  causes 


598  CAUSES  OF  CONSTIPATION. 

that  may  give  rise  to  constipation,  I  shall  now  discuss 
more  particularly  those  cases  of  habitual  disorder  of  this 
kind  so  often  occurring  in  practice,  and  generally  to  be 
ascribed  to  sluggish  peristaltic  action  of  the  bowel. 
Besides  the  causes  already  mentioned  there  are  several 
others  which  must  not  be  passed  over.  The  peristaltic 
action  of  the  bowel  may  be  temporarily  enfeebled  by 
over-action  and  simple  fatigue,  induced  by  severe 
diarrhoea  or  the  action  of  medicines  ;  and  it  may  be 
permanently  weakened  by  repeated  drastic  purgatives. 
Many  sufferers  from  habitual  constipation  aggravate 
their  disorder  by  the  frequent  use  of  these  medicines, 
and  the  effect  of  this  practice  is  that  a  constantly 
increasing  degree  of  irritation,  obtained  either  by  in- 
creasing the  dose  or  by  employing  still  more  powerful 
drugs,  is  required  to  induce  the  peristaltic  action  of  the 
bowels.  The  habitual  use  of  pills,  "  liver-regulators  " 
and  so-called  "  vegetable  aperients,"  in  great  demand 
by  maid-servants,  as  well  as  that  of  the  purgative 
mineral  waters  among  the  upper  classes,  is  a  fertile 
source  of  constipation.  In  the  course  of  time  the  reflex 
activity  of  the  bowel,  whose  natural  stimulus  is  the 
intestinal  contents,  is  never  brought  into  play  except  by 
artificial  aid.     Besides  increasing  the  constipation,  the 


CAUSES  OF  CONSTIPATION. 


599 


habitual  use  of  purgatives  leads  to  chronic  catarrh  of 
the  mucous  membrane_,  tumefaction  and  hypertrophy  of 
the  muscular  coat,  diminished  excitability^  tonicity  and 
reflex  contractile  power,  distension  of  the  bowels  and 
various  displacements^  proctitis  and  follicular  ulceration 
in  the  colon.  Chronic  peritonitis,  with  the  formation 
of  fibrous  bands,  is  another  consequence  of  constipation 
and  of  attempts  to  relieve  it  by  injudicious  methods.  T 
have  recently  seen  a  case  in  a  young  lady  in  whom  con- 
stipation was  aggravated,  if  not  induced,  by  tight  lacing. 
Pressure  on  the  ascending  and  descending  colon  as  a 
result  of  the  constriction  and  faecal  accumulation  had 
set  up  ulceration  about  the  appendix  caeci,  and  this  w^as 
followed  by  perforation  and  localized  peritonitis. 

Another  cause  of  constipation  is  obstruction  of  the 
portal  circulation,  either  directly,  as  in  cirrhosis  or  by  a 
tumour;  or  as  a  result  of  heart-disease  interrupting  the 
return  of  blood  through  the  vena  cava,  and  causing 
venous  congestion  and  chronic  intestinal  catarrh. 

Insufficiency  of  food  is  another  cause  of  constipa- 
tion, and  cases  of  this  kind  are  often  seen  among 
women  whose  food  is  inadequate  in  quantity  to  excite 
the  peristaltic  action  of  the  bowels.  The  nature  of  the 
food   is  not  without  influence;   if  it  consist  mainly  of 


6oo  DIAGNOSIS  OF  CONSTIPATION. 


farinaceous  articles,  such  as  bread,  potatoes,  rice,  and 
pastry^  and  especially  if  these  be  washed  down  by 
draughts  of  tea,  constipation  is  very  apt  to  be  induced. 
Some  kinds  of  tea  are  especially  mischievous  in  these 
respects,  owing  to  the  large  proportion  of  tannin 
they  contain.  The  influence  of  this  constituent  upon 
salivary    digestion    has    been    already    alluded    to    (see 

p.  485). 

The  diagnosis  of  constipation  can  never  be  difficult 
if  a  proper  examination  be  made.  Individual  peculi- 
arities with  regard  to  the  action  of  the  bowels  must,  of 
course,  be  borne  in  mind;  and  it  must  never  be  for- 
gotten that  very  decided  constipation  may  exist,  not- 
withstanding regular  evacuations,  if  of  an  insufficient 
quantity.  It  not  unfrequently  happens  that  a  portion 
of  the  fasces  which  ought  to  be  discharged  at  each 
evacuation  is  retained,  and  an  accumulation  thus 
gradually  takes  place,  eventually  becoming  very  con- 
siderable. Under  such  circumstances  faeces  mav  be 
discharged  froin  the  rectum,  and  when  they  are 
accompanied  by  much  mucus,  the  result  of  irritation, 
the  patient  may  fancy  that  he  is  suffering  from 
diarrhoea.  A  careful  examination  of  the  abdomen  and 
rectum  will  detect  the  true  state  of  things.     A  tumour 


TREATMENT  OF  CONSTIPATION.  6oi 

will  often  be  detected  in  some  part  of  the  colon  and  the 
rectum  will  be  found  full  of  faeces. 

It  must  be  remembered  that  obstinate  constipation 
is  a  symptom  of  many  affections  of  the  brain  and 
spinal  cord,  of  diseases  of  the  liver,  heart,  and  lungs,  of 
mechanical  impediments  to  the  passage  of  faces,  and 
of  disorders  attended  with  copious  eUmination  of  water 
bv  the  skin  or  kidneys. 

The  treatment  of  constipation  may  be  considered 
under  two  heads :  i.  The  means  of  dealing;  with 
occasional  attacks,  and  2.  The  course  to  be  adopted  for 
tases  in  which  the  condition  is  habitual.  For  occa- 
sional attacks  we  may  have  recourse  to  purgatives  or 
laxatives,  proportionate  in  their  activity  to  the  circum- 
stances of  the  case;  and  it  is  always  well  to  give 
mild  remedies  at  first.  Of  these,  castor-oil  is  one  of 
the  best,  and  its  nauseous  taste,  its  only  drawback, 
should  be  disguised  by  the  addition  of  oil  of  almonds, 
or  other  flavouring  material.  Saline  purgatives,  of 
wdiich  the  sulphates  of  sodium  and  magnesium  and 
the  phosphate  of  sodium  may  be  taken  as  the  type,  are 
suitable  for  those  cases  in  which  constipation  is  accom- 
panied by  febrile  movement,  and  for  gouty  and 
plethoric  subjects.      The  alkaline    carbonates  may   be 


6o2     TREATMENT  OF  OCCASIONAL  CONSTIPATION. 

added  with  advantage_,  and  if  it  be  desired  to  produce 
a  more  decided  effect  the  salts  may  be  dissolved  in 
infusion  of  senna^  qualified  by  the  addition  of  aromatics. 
A  draught  containing  rhubarb^  soda^  magnesia,  and 
aromatics  is  an  old-fashioned  remedy  for  constipation  ; 
it  is  suitable  for  cases  in  which  the  condition  is 
temporary  and  due  to  an  error  in  diet.  The  more 
active  purgatives,  such  as  jalap,  colocynth,  scammony, 
and  gamboge,  are  seldom  required  for  the  cases  under 
consideration.  The  pil.  colocynth.  et  hyoscyami  is, 
however,  a  good  combination,  and  is  suitable  for 
occasional  use.  If  it  be  wished  to  act  decidedly  on  the 
liver,  in  cases  in  which  torpidity  of  that  organ  is 
associated  with  the  constipation,  3  or  4  grains  of 
calomel  or  blue  pill  should  be  given,  and  followed  in  a 
few  hours'  time  by  the  salts  and  senna  draught.  All 
the  remedies  just  mentioned  are  suitable  only  for  occa- 
sional use;  they  are  not  adapted  for  habitual  constipa- 
tion. 

In  the  cases  under  discussion,  should  the  purgative 
prove  ineffectual,  or  should  its  use  be  unadvisable  by 
reason  of  the  irritability  of  the  stomach,  the  employ- 
ment of  enemata  becomes  indispensable.  The  safest 
and  most  efficient  substance  for  this  purpose  is  simple 


ENEMATA  AND  ELECTRICITY.  603 


warm  water  injected  into  the  bowel  in  large  quantities, 
and  repeated  so  as  gradually  to  soften  and  wash  away 
the  faeculent  matter.  It  may  be  necessary  to  aid  the 
contractile  powder  of  the  sphincter  by  twisting  a  towel 
round  the  tube  of  the  enema-syringe,  and  pressing  it 
against  the  perineum.  It  is  sometimes  advantageous, 
and  indeed  necessary,  to  introduce  the  water  directly 
into  the  colon  through  a  suitable  tube  passed  high  up 
into  the  bowel.  If  warm  water  fail  to  produce  any 
effect,  recourse  may  be  had  to  enemata  containing  tur- 
pentine, sulphate  of  magnesium,  or  aloes.  In  cases  of 
impaction  of  faeces  in  the  rectum,  the  employment  of  a 
scoop  or  some  similar  instrument  becomes  necessary 
in  order  to  break  up  the  solid  mass.  By  way  of  aiding 
the  effect  of  injections,  we  may  have  recourse  to  friction 
over  the  abdomen  and  loins,  or  allow  a  stream  of  cold 
water  to  fall  upon  their  surface.  The  application  of 
cloths  wetted  with  cold  water  sometimes  proves 
effectual,  and  if  all  these  measures  fail,  faradism  should 
be  tried.  For  this  purpose,  the  rectum  having  been 
emptied,  one  pole  constructed  for  the  purpose  is  intro- 
duced within  the  bowel,  while  the  other  is  moved  gently 
over  the  abdomen,  especially  over  the  position  of  the 
colon  from    right  to   left.     The  application  should  be 


6o4        TREATMENT  OF  CHRONIC  CONSTIPATION. 

continued  for  ten  or  fifteen  minutes;  the  results  are 
sometimes  very  satisfactory. 

The  chronic  forms  of  constipation  require  treatment, 
differing  in  many  respects  from  that  just  laid  down. 
In  the  first  place,  attention  must  be  paid  to  the  removal 
of  the  cause,  which  will  often  be  discoverable  on 
inquiry.  The  patient  should  be  instructed  to  endeavour 
to  acquire  the  habit  of  regular  evacuations  by  daily 
visits  to  the  closet;  but  straining  should  be  avoided  as 
likely  to  cause  prolapsus  ani  and  haemorrhoids.  When 
opposite  conditions  have  apparently  contributed  to  pro- 
duce the  constipation,  regular  habits  of  life,  moderate 
exercise,  and  relaxation  from  intense  mental  toil,  with 
change  of  air  and  scene,  often  prove  valuable  auxiliaries 
to  the  measures  about  to  be  discussed.  Cold  or  tepid 
baths,  according  to  the  state  of  the  patient,  should 
never  be  omitted ;  they  often  aid  greatly  in  restoring 
tone  to  the  bowels. 

The  regulation  of  the  diet  is  all-important,  and  in 
some  cases  wall  prove  sufficient  to  induce  a  proper 
action  of  the  bowels.  The  food  should  be  sufficient  in 
quantity,  taken  at  regular  intervals,  and  of  a  digestible 
character,  containing  a  due  amount  of  vegetables  and 
fruits.       Certain  articles    of  diet  possess  laxative  pro- 


HYGIENIC  MEASURES.  605 

perties^  and  these  are  generally  suitable  unless  they 
irritate  the  stomach.  One  of  the  best  of  these  is  bread 
made  from  ^^  whole  meal ;  "  only  the  silicious  envelope 
is  removed  from  the  wheat,  the  whole  grain  being  then 
ground  into  moderately  fine  flour.  Some  patients  can 
eat  with  advantage  the  so-called  "  brown  bread/'  which 
contains  a  considerable  quantity  of  bran_,  very  coarsely 
ground.  Either  kind  should  be  taken  whenever  bread 
is  eaten ;  except  among  ignorant  persons,  the  prejudice 
in  favour  of  white  bread  is  soon  got  over.  Porridcre 
may  also  be  recommended  for  the  same  purpose ;  some 
persons  find  that  it  acts  admirably  as  a  regulator  of  the 
bowels.  When  the  stomach  is  free  from  irritation, 
fresh  and  dried  fruits  are  often  very  serviceable  in  cases 
of  constipation;  patients  find  this  out  for  themselves^ 
they  are  often  free  from  their  discomfort  when  ripe 
fruits  are  procurable.  The  most  suitable  of  these  are 
gooseberries,  currants,  and  strawberries,  ripe  pears  and 
apples ;  the  latter  should  generallv  be  cooked.  In 
winter,  and  when  other  fruits  are  not  procurable, 
oranges,  figs,  and  prunes  may  be  used  instead.  Ringer 
recommends  an  orange  or  two  to  be  taken  before  break- 
fast as  a  pleasant  and  often  effectual  way  of  overcoming 
habitual  constipation.     Among  various   articles  of  diet 


6o6         TREATMENT  OF  CHRONIC  CONSTIPATION. 

which  have  a  beneficial  effect  in  these  cases  may  be 
mentioned  honey,  treacle^  buttermilk^  and  bacon.  Milk 
should  be  rather  sparingly  used  by  these  patients,  and 
especially  by  children  who  are  subject  to  constipation. 
With  regard  to  fluids,  care  should  be  taken  that  the 
daily  quantity  is  not  too  small ;  tea  should  be  avoided 
on  account  of  the  tannin  it  contains^  but  coffee  is  less 
harmful ;  in  some  cases,  indeed,  it  appears  to  exhibit 
laxative  properties.  Water  constitutes  the  best  drink, 
and  it  should  be  taken  freely  with  meals ;  some  patients 
find  that  a  glass  of  cold  water  taken  while  dressing  .has 
a  satisfactory  effect.  Stimulants  should  be  avoided  as 
much  as  possible;  if  their  use  has  become  a  necessity 
a  little  sound  bitter  beer,  or  a  glass  or  two  of  hock  may 
be  allowed;  claret  should  be  avoided,  as  it  is  more  or 
less  astringent  in  its  action. 

In  most  of  the  cases  of  constipation  that  come  under 
the  notice  of  the  physician,  laxative  medicines  of  some 
kind  are  indispensable.  The  patients  have  usually  had 
recourse  to  first  one  and  then  another  aperient  drug; 
indeed,  the  number  of  those  advertised  is  a  measure  of 
the  extent  to  which  the  disorder  prevails.  It  is  neces- 
sary to  emphasize  one  point  in  starting,  viz.,  the  injury 
which  these  persons  inflict  upon   themselves  by  taking 


USE  OF  LAXATIVES.  607 

doses  of  strong  purgatives.  Relief  may  be  gained  for 
the  time^  but  at  the  cost  of  aggravating  the  original 
disorder.  The  restoration  of  the  natural  action  of  the 
bowels  is  the  indication  to  be  fulfilled. 

In  the  choice  of  laxatives  the  physician  has  to  deter- 
mine whether  salines  or  drugs  belonging  to  the  vegetable 
kingdom  are  likely  to  prove  the  more  suitable,  and  per- 
haps for  the  majority  of  cases  remedies  belonging  to  the 
latter  class  will  best  answer  the  purpose.  In  dealing  with 
a  case  of  habitual  constipation  complicated  probably 
with  dyspepsia,  we  may,  after  regulating  the  diet  and 
mode  of  life  as  far  as  practicable,  prescribe  some  such 
combination  as  the  following  : — R.  Extract.  Aloes  Socot. 
gr.  j-iss.;  Extract.  Belladonna  gr.  J;  Quininse  Sulphat. 
gr.  j.;  Extract.  Hyoscyam.gr.  j.  ft.  pil.  j.  A  dozen  of  these 
pills  should  be  given  to  the  patient  with  the  instructions 
that  he  should  take  one  daily  before  dinner,  and  after  a 
few  days  try  whether  one  every  other  day  \\n\\  answer 
the  requirements.  Purging  is,  of  course,  to  be  avoided, 
and  if  improvement  result  it  will  be  well  graduallv  to 
diminish  the  dose.  For  some  patients  the  sulphate  of 
iron  may  be  substituted  for  the  quinine,  but  the  combi- 
nation as  given  above  will  be  found  a  very  useful  one. 
Another  drug,  recently  introduced,  the  cascara  sagrada. 


6o8         TEEATMUNT  OF  CHRONIC  CONSTIPATION. 

is  of  great  value  in  many  of  these  cases,  and,  like 
aloes,  it  possesses  tonic  as  well  as  aperient  properties. 
It  is  best  administered  in  the  form  of  the  liquid  extract 
of  the  pharmacopoeia,  the  dose  being  Ti|  xv-xx  twice  or 
three  times  a  day,  and  gradually  diminished  as  soon  as 
a  satisfactory  effect  results.  Various  palatable  prepara- 
tions of  the  drug  are  to  be  found  at  the  chemists,  and 
of  these  Messrs.  Squire's  "  elixir  "  is  one  that  can  safely 
be  recommended.  Some  patients  find  by  experience 
that  castor-oil  relieves  habitual  constipation^  and  that 
the  dose  may  be  gradually  lessened  until  a  teaspoonful 
proves  sufficient.  Senna  is  another  purgative  often 
employed,  and  it  may  be  conveniently  administered  in 
the  form  of  the  compound  liquorice  powder  of  the 
pharmacopoeia.  The  bulk  and  sweet  taste  of  this  powder 
are  somewhat  objectionable.  Senna  may  also  be  given 
in  the  form  of  confection,  to  which  a  similar  prepara- 
tion of  sulphur  and  black  pepper  may  be  added  with 
advantage,  especially  for  patients  with  a  tendency  to 
haemorrhoids.  Rhubarb  is  not  suitable  for  chronic 
constipation.  Its  employment  tends  to  perpetuate  the 
condition,  and  the  same  remark  applies  to  the  stronger 
purgatives,  such  as  colocynth,  jalap,  and  scammony. 
Bitter  tonics  will  often  aid  the  effect  of  laxatives,  and  a 


SALINE  P  UR  a  A  TI VES.  609 

course  of  such  medicines  as  quassia,  gentian_,  calumba, 
or  cascarilla,  with  alkaHes  or  acids  according  to  circum- 
stances,   will    often    prove    advantageous.       The    nux 
vomica    is   perhaps   the   most  valuable  remedy  of  this 
class,  and  it  suffices  in  some  cases  to  relieve  habitual 
constipation.     For  this  purpose  Vi\  viii-x  of  the  tincture 
should  be  taken  every  morning.     It  is  especially  indi- 
cated whenever  there  is  pronounced  atony  of  the  bowels, 
and  much  gastric    or   intestinal  flatulence.     For  these 
latter   cases  gr.   ^   of   the   extract  will  advantageously 
replace  the  quinine  in  the  pills  mentioned  in  a  preceding 
paragraph,    and    when    the    intestinal    secretions    are 
deficient,  gr.  J  of  ipecacuanha  may  be  added  to  each  pill. 
In  plethoric  subjects,  and  whenever  there  are  evidences 
of  functional  derangement  of  the  liver,  saline  aperients 
are    generally    indicated.     These    act    promptly,    and 
besides   removing  the    contents    of   the    bowels,    they 
cause  a  decided   drain  from  the  intestinal  vessels,  and 
relieve    congestion    of   the    portal    system.      It   would 
appear  that  they   prevent  the  absorption  of  the  intes- 
tinal secretions  which  are  taken    up   by  the  veins  and 
lymphatics.     The  salts   best  adapted   for  the    purpose 
are    the    sulphates    of    sodium    and    magnesium,    the 
phosphate  of  sodium  and   the  tartarated  soda.     These 

39 


6io        TREATMENT  OF  CHRONIC  CONSTIPATION. 

may  be  given  in  the  ordinary  manner,  but  a  very  con- 
venient v^ay  of  exhibiting  them  is  in  the  form  of  some  one 
or  other  of  such  niineral  waters  as  Friedrichshall,  PiiUna, 
Kissingen,  JEsculap,  or  Hunyadi  Janos.  The  Rubinat-. 
Condal,  a  Spanish  mineral  water,  contains  a  large 
percentage  of  sodium  sulphate,  and  a  small  proportion 
of  magnesium ;  it  is  free  from  the  bitter  taste  so 
objectionable  in  many  of  these  waters,  and  does  not 
depress  the  system.  The  dose  of  any  of  these  varies 
according  to  circumstances ;  from  two  to  six  fluid 
ounces  may  be  required.  It  is  generally  advisable  to 
add  an  equal  quantity  of  hot  water  -,  and  the  medicine 
should  be  taken  about  half-an-hour  before  breakfast. 
The  quantity  should  be  so  regulated  as  to  produce  one, 
or  at  most  two  evacuations,  without  griping  or  dis- 
comfort. It  is  often  advantageous  to  combine  tonics 
with  salines;  thus  the  sulphate  of  quinine  with  a  little 
sulphuric  acid  may  be  added  to  the  sulphates  of 
magnesium  and  sodium. 

When  the  constipation  is  associated  with  symptoms 
of  gastric  catarrh,  fermentation  and  acidity,  Carlsbad 
water  is  preferable.  The  principal  salts  contained  in 
the  Sprudel  spring  are  the  sulphate,  carbonate,  and 
chloride  of  sodium.     These  salts  may   be  obtained  in 


LAX  A  TIVE  MEDICINES.  6 1 1 

the  dry  state^  and  when  dissolved  in  water  are  very 
efficacious.  About  a  teaspoonful  should  be  added  to 
half-a-pint  of  boiling  water_,  and  when  the  solution  has 
cooled  down  to  120°,  two  or  three  ounces  should  be 
taken  every  five  minutes.  The  salts  may  be  thus  taken 
every  morning  or  every  other  morning  according  to 
circumstances,  and  the  dose  may  be  increased,  if 
necessary,  or  one  of  the  aloes  pills  may  be  taken  before 
dinner. 

In  cases  of  constipation  dependent  upon,  or  asso- 
ciated with  functional  disorder  of  the  liver,  certain 
vegetable  drugs  may  be  used  with  advantage,  the  chief 
among  them  being  podophyllin,  iridin^  euonymin,  and 
leptandrin.  All  these  rank  as  cholagogues  and  aperients. 
The  resin  of  podophyllum  in  doses  of  gr.  \-\  may  be 
conveniently  combined  with  aloes,  capsicum,  and  bella- 
donna in  the  form  of  a  pill ;  the  dose  of  iridin  is  from 
one  to  five  grains,  and  of  euonymin  about  the  same 
quantity;  leptandrin  is  given  in  doses  of  two  grains. 
The  three  last-named  drugs  are  less  irritating  to  the 
intestines  than  podophyllum.  As  a  tonic  for  the  cases 
under  discussion,  the  most  suitable  is  the  nitro- 
muriatic  acid,  with  the  tinctures  of  nux  vomica  and 
hyoscyamus  in  infusion  of  chiretta. 


6i2      treatmt:nt  of  chronic  constipation. 

For  habitual  constipation  in  general.  Trousseau 
recommends  belladonna  in  doses  of  gr.  ^-J  of  the 
extract  either  night  or  morning,  increased  if  required, 
and  diminished  or  discontinued  when  the  constipation 
is  removed.  It  should  be  tried  for  a  fortnight  or  three 
weeks.  Dr.  Nunneley,  cited  by  Ringer,  "  finds  this 
treatment  useful  in  all  forms  of  constipation,  especially 
when  coexisting  with  dyspepsia,  characterized  by  a 
thinly-furred  tongue,  with  prominent  red  papillae  at  the 
tip,  epigastric  tenderness,  pain  after  food,  and  often 
more  or  less  headache." 

Many  persons  employ  enemata  as  substitutes  for 
cathartics  by  the  mouth,  administering  them  daily  or 
every  other  day.  The  practice  is  liable  to  several 
objections  ;  if  used  warm,  enemata  are  apt  to  cause  a 
torpid  condition  of  the  intestines ;  moreover,  they 
apply  to  one  part  of  the  bowels  the  irritation  which 
laxatives  spread  more  or  less  over  the  whole  tract,  and 
thev  do  not  empty  the  upper  part  of  the  canal.  Their 
frequent  use  also  washes  away  the  mucus  intended  to 
lubricate  the  surface  of  the  bowel.  In  cases  in  which 
there  is  a  tendency  to  haemorrhoids  or  prolapsus  ani,  it 
is  well  to  inject  two  or  three  ounces  of  cold  water  after 
the  bowels  have  been  moved. 


VARIOUS  REMEDIES.  613 

Among  the  remedies  for  the  relief  of  chronic  con- 
stipation it  is  only  necessary  to  mention  faradisiii^ 
already  referred  to ;  frictions  to  the  abdomen^  with 
coarse  flannel,  or  the  flesh  brush,  and  tepid  or  cold 
douches.  Some  persons  find  that  smoking  after 
breakfast  produces  the  desired  effect.  One  caution 
must  be  borne  in  mind  with  regard  to  laxative  medicines. 
They  are  to  be  regarded  only  as  adjuvants  to  more 
rational  methods ;  the  dose  should  be  no  larger  than 
absolutely  necessary,  and  the  drugs  should  be  dis- 
continued when  they  are  no  longer  absolutely  required. 


CHAPTER     VIII. 

DIARRHCEA. 


DiARRH(EA,  Conditions  for  its  Production — Causes,  Food,  Cold, 
Mental  Excitement,  Summer  Diarrhcea — Diarrh(ea  Accom- 
panying Intestinal  Lesions  and  Various  Morbid  Conditions 
— Persons  most  Subject  to  Attacks — Anatomical  Appear- 
ances— Symptoms  in  Adults — Influence  on  General  Condi- 
tion— Severe  Attacks — Diagnosis — Treatment,  Question  as 
TO  Arresting  Discharges — Sometimes  Desirable  to  Facili- 
tate them — Castor  Oil,  Sulphate  of  Sodium,  Rhubarb,  ANr> 
Calomel — For  Checking  Diarrhcea,  Opium,  Aromatics  and 
Astringents,  Camphor,  Warmth,  Stimulants  —  Chronic 
Diarrhcea — Diet  and  Regimen — Rest — Diarrhcea  in  Chil- 
dren— Causes  of  Frequency — Disorders  of  Digestion — Com- 
plications— Treatment,  Cautions  as  to  use  of  Opiates — 
Warm  Baths,  Stimulants,  Flannel  to  Surface—Diet — Ene- 
MATA  OF  Warm  Water — Calomel — Cautions  as  to  Excessive 
Feeding — Chronic  Diarrhcea — Diet,  Flannel  and  Warmth — 
Grey  Powder,  Vegetable  Astringents,  Chalk,  Bismuth, 
Perchloride  of  Mercury,  Arsenic,  Iron, 

Diarrhcea,  owing  to  its  frequency,  occupies  a  promi- 
nent place  among  the  functional  disorders  of  the  abdo- 
men ;  it  is  also  a  common  symptom  of  many  organic 
lesions  of  the  abdominal  viscera.  The  term  is  used  to 
signify  discharges  from  the  bowel  more  fluid  and 
usually  more  abundant  than   those  of  health.     Three 


CAUSES  OF  DIARRH(EA.  615 

conditions  are  necessary  for  the  production  of  diarrhoea  : 
(1)  increased  peristaltic  action,  (2)  free  communication 
between  the  upper  portions  of  the  intestines  and  the 
lower  end  of  the  bowel,  and  (3)  the  presence  of  contents 
capable  of  being  propelled  along  the  canal. 

The  following  are  the  principal  causes  of  diarrhoea : — 

I.  The  passage  of  substances  from  the  stomach  into 
the  intestines,  capable  of  accelerating  the  peristaltic 
movements  of  the  latter,  either  with  or  witht)ut  the  pro- 
duction of  inflammation.  Articles  of  diet  of  this 
character  have  been  already  described  in  the  chapter  on 
Indigestion,  and  the  fact  must  be  borne  in  mind  that 
peristaltic  movements  of  the  stomach  thus  induced 
may  be  propagated  thence  to  the  intestines,  and  cause 
movements  of  a  similar  character  along  the  entire  tract. 
Thus  it  is  that  in  some  persons  a  little  cold  water  taken 
fasting  in  the  early  morning,  is  sufficient  to  produce 
free  action  of  the  bowels.  Under  pathological  condi- 
tions, in  which  the  excitability  of  the  parts  is  increased^ 
such  propagation  of  movement  is  often  witnessed  under 
the  operation  of  comparatively  slight  stimuli.  Cases  in 
which  the  irritation  proceeds  from  the  stomach  must  be 
distinguished  from  those  in  which  the  intestines  form 


6i6  CAUSES  OF  BIARRHCEA. 

the  Starting-point ;  but  it  often  happens  that  both  parts 
a?e  implicated.  A  distinction  must  also  be  drawn 
between  such  materials  as  cause  inflammation  as 
well  as  diarrhoea  and  those  which  do  not  induce  the 
former ;  in  this  last  category  may  be  placed  many 
articles  of  food ;  fluids,  especially  water,  and  laxative 
medicines  of  a  non-irritating  kind. 

Z.  Another  common  cause  of  diarrhoea  is  exposure 
to  cold,  and  particularly  when  the  abdomen  itself  is 
thus  acted  upon.  The  manner  in  which  the  effect  is 
produced  is  by  no  means  certain^  but  the  sequence  of 
the  two  events  is  often  beyond  doubt.  Many  persons 
are  liable  to  diarrhoea  after  exposure  to  cold,  and  espe- 
cially if  damp  be  combined  with  the  cold.  In  such 
cases  it  is  generally  said  that  the  alimentary  canal  is  a 
locus  minoris  resistentice.  It  may  be  that  the  diarrhoea 
is  the  result  of  transudation  into  the  intestines,  taking 
place  as  a  consequence  of  paralysis  of  the  vaso-motor 
nerves.  Cold  often  acts  very  energetically  after  previous 
exposure  to  heat,  and  especially  when  the  body  is  per- 
spiring freely. 

3.  In  a  less  numerous  class,  diarrhoea  is  apt  to  set  in 
suddenly  as  a  result  of  nervous  excitement,  e.g.,  terror 
or  anxiety,  the  stomach  being  sometimes  aflfected  at  the 


CA  USES  OF  DIA RRR(EA .  617 

same   time,  as    shown   bv   eructations    and    vomitino". 
This  form  is  not  uncommon  in  hysterical  patients. 

4.  Another  category  embraces  those  forms  of 
summer  and  autumnal  diarrhoea^  the  cause  of  which 
is  doubtful,  but  is  probably  of  an  infectious  nature: 
the  stomach  is  often  disordered  at  the  same  time. 

Diarrhoea  induced  by  any  of  the  above-mentioned 
causes  is  rapidly  developed  and  of  an  acute  character. 
Under  proper  treatment  it  may  quickly  subside, 
and  such  is  the  general  rule  in  subjects  otherwise 
healthy.  It  may,  however,  become  a  chronic  disorder, 
liable  to  exacerbations.  Diarrhoea  of  this  latter  type 
frequently  occurs  in  association  with  disorders  of 
nutrition  and  various  pathological  lesions  or  other 
circumstances  which  prevent  the  restoration  of  a 
healthy  action.  Intestinal  lesions  and  disorders  are 
by  no  means  always  attended  by  diarrhoea,  and 
therefore  must  be  regarded  as  only  a  predisposing  cause 
thereof.  As  a  matter  of  fact  they  produce  the  result 
in  question  by  setting  up  a  condition  of  catarrh  in  the 
intestines;  if  they  fail  in  this  respect,  severe  disorders, 
such  as  extensive  ulceration,  may  exist  without 
diarrhoea.     The  latter  invariably  accompanies  catarrhal 


6i8  CAUSES  OF  JDIAERSCEA. 

inflammation  of  the  colon,  and  is  apt  to  become  very- 
marked  as  the  complaint  continues. 

The  intestinal  lesions  and  various  conditions  often 
accompanied  by  diarrhoea  are  as  follows  : — 

I.  Ulceration  occurring  in  the  course  of  specific 
infectious  disorders,  such  as  typhoid  fever,  dysentery, 
and  intestinal  tuberculosis. 

^.  Disordered  movement  of  the  blood  in  the  intes- 
tines, such  as  results  from  obstruction  to  the  flow  in 
the  vena  portae.  This  condition  exists  in  those  diseases 
of  the  liver  which  produce  compression  of  the  capillary 
system  of  the  or^an,  and  in  cases  in  which  the  intes- 
tines  are  agglutinated  together  as  a  consequence  of 
chronic  peritonitis.  Congestion  of  the  intestinal  veins 
is  also  liable  to  occur  in  those  cardiac  and  pulmonary 
disorders  in  which  the  flow  of  blood  from  the  inferior 
cava  is  impeded.  Faecal  obstruction  is  another  obstacle 
of  a  mechanical  kind  to  the  flow  of  blood,  and  it  may 
produce  symptoms  of  diarrhoea  by  causing  intestinal 
catarrh. 

3.  Attacks  of  diarrhoea  are  common  symptoms  of 
such  constitutional  disorders  as  rickets  and  scrofula. 

There  is  one  condition  of  the  bowels,  viz.,  amyloid 


CAUSES  OF  DIARRECEA.  619 

degeneration,  of  which  diarrhoea  is  a  marked  symptom. 
Once  set  up,  it  is  apt  to  b.e  almost  uncontrollable,  and 
continues  until  death. 

Besides  the  infectious  disorders  above  mentioned 
which  are  localized  in  the  bowels^  and  are  always 
attended  by  diarrhoea,  there  are  other  infectious  com- 
plaints which  are  often  similarly  accompanied.  Thus, 
various  septic  processes,  such  as  occur  in  puerperal 
fever  and  disorders  of  a  different  character,  viz.,  scarlet 
fever  and  uraemia,  are  not  unfrequently  attended  with 
discharges  from  the  bowels.  It  is  probable  that  a 
portion  of  the  virus  acts  upon  the  intestinal  mucous 
membrane,  and  is  thus  got  rid  of;  evacuations  of  this 
character  may  sometimes  be  regarded  as  favourable. 
In  fatal  cases,  however,  various  lesions  are  discoverable 
in  the  intestines,  such  as  indications  of  catarrh,  extra- 
vasations of  blood  in  the  mucous  and  submucous 
coats,  and  even  ulcers'as  a  result  of  necrosis.  In  non- 
fatal cases  the  diarrhoea  may  be  regarded  as  of  a  func- 
tional character. 

Persons  of  all  ages  are  liable  to  suffer  from  diarrhoea, 
but  the  complaint  is  especially  frequent  among  infants 
under  two  years  old.  This  frequency  is  due  in  part, 
though  not  altogether,  to  bad  feeding.     There  are  great 


620  SYMPTOMS  OF  BIARRRGEA. 

differences  among  individuals  with  regard  to  liability  to 
attack.  The  same  cause  which  affects  one  person  will 
be  harmless  to  others.  As  a  general  rule  weakly 
subjects  are  prone  to  suffer^  and  the  complaint  in 
such  subjects,  once  set  up,  is  apt  to  be  violent  and 
obstinate. 

The  anatomical  changes  in  cases  of  diarrhoea  can  be 
disposed  of  in  a  few  words.  In  many  cases  little  or 
nothing  is  discoverable,  for  signs  of  congestion  often 
subside  after  death.  In  other  cases  there  is  more  or  less 
catarrh,  with  production  of  much  mucus  and  detachment 
of  epithelium;  infiltration  of  the  connective  tissue  with 
fluid  and  cells.  In  chronic  cases  atrophy  of  the  mucous 
membrane  is  often  observed.  When  the  diarrhoea  has 
been  associated  with  specific  disorders  the  changes 
peculiar  to  these  latter  will,  of  course,  be  noticeable. 

In  describing  the  symptoms  and  treatment  of  diar- 
rhoea it  is  well  to  make  a  distinction  between  the  com- 
plaint as  it  occurs  in  adults  and  those  forms  of  it  which 
are  common  in  children.  Important  differences  exist  in 
several  particulars. 

In  adult  cases  an  attack  of  acute  diarrhoea  usually 
begins  with  a  feeling  of  uneasiness  in  the  abdomen, 
which   soon   amounts   to  pain  of  a  griping  character. 


SYMPTOMS  OF  BIARRHCEA.  bii 

Rumbling  sounds  are  caused  in  the  abdomen,  which 
becomes  somewhat  distended.  A  desire  to  defaecate  is 
then  experienced^  and  is  soon  felt  to  be  uncontrollable. 
Evacuation  takes  place  with  some  force;  fluid  and 
gaseous  matters  are  dischar2;ed  with  the  more  solid 
faeces,  and  the  stool  is  often  frothy.  After  the  motion 
the  abdominal  pain  and  uneasiness  are  relieved,  and 
perhaps  quite  subside,  but  there  is  often  a  feeling  of 
insecurity,  warranted  by  a  speedy  return  of  the  colicky 
pains  and  discharge  of  faeces.  When  the  lower  part  of 
the  large  intestine  is  especially  implicated,  tenesmus  is 
a  common  symptom.  Passage  of  the  motions  does  not 
bring  relief,  the  patient  is  worried  by  the  feeling  that 
something  remains  in  the  rectum,  and  he  makes  strain- 
ing efforts  to  get  rid  of  it.  He  may  even  feel  that  he 
scarcely  dares  to  leave  the  closet  or  night-chair;  his 
efforts  sometimes  cause  more  or  less  prolapsus  of  the 
rectum,  with  aggravation  of  his  troubles.  The  matters 
discharged  are  at  first  pulpy,  with  the  appearance  and 
odour  of  faeces.  Gradually  they  become  more  liquid, 
and  eventually  non-faeculent,  consisting  of  fluid  matters 
containing  much  mucus,  and  more  or  less  coloured  with 
bile.  In  some  cases  diarrhoea  sets  in  with  two  or  three 
loose  watery  motions  in  rapid  succession,  the  disturb- 


62  2  SYMPTOMS  OF  BIARRHCEA. 

ance  then  subsiding  and  stools  of  natural  consistence 
making  their  appearance. 

Diarrhoeal  discharges  are  sometimes  unattended  by 
pain,  but  as  a  general  rule  they  are  preceded  by  the 
sensations  above  described.  Sometimes  painful  and 
painless  discharges  alternate  in  the  same  patient.  The 
presence  or  absence  of  pain  is  no  indication  of  the 
special  form  of  disorder  present.  When  the  attack  is 
due  to  irritating  ingesta,  pain  of  a  griping  character  is 
seldom  absent.  In  ulceration  of  the  bowel  it  is  also  a 
common  symptom^  and  is  accompanied  by  tenderness 
on  pressure. 

Unless  of  a  very  slight  character  an  attack  of 
diarrhoea  is  seldom  without  influence  on  the  general 
condition  of  the  patient.  Thirst  is  often  experienced 
as  a  result  of  the  withdrawal  of  fluid  from  the  system. 
The  urinary  secretion  is  lessened,  its  colour  becomes 
deeper,  its  specific  gravity  is  increased,  and  a  sediment 
composed  of  urates  is  apt  to  be  deposited  when  the 
urine  gets  cold.  More  or  less  weakness  and  depression 
are  experienced  by  the  patient,  and  his  appearance  is 
altered  for  the  worse.  There  is  generally  some  loss  of 
appetite,  even  when  the  stomach  is  not  involved  in  the 
attack. 


TREATMENT  OF  DIABRHCEA.  623 

After  very  frequent  stools  and  copious  discharges, 
resulting  in  the  abstraction  of  much  fluid  from  the 
tissues,  the  patient's  appearance  may  closely  resemble 
that  which  is  seen  in  cases  of  cholera  :  the  prostration 
is  intense;  the  features  are  sunken  so  that  even  a 
young  patient  looks  aged  ;  the  skin  is  cold  ;  the  pulse 
small  and  frequent;  there  are.  muscular  twitchings, 
suppression  of  urine  and  diminution  of  temperature. 
In  children  general  convulsions  are  sometimes  caused 
by  diarrhoea;  adults  often  become  listless  and  apathetic. 
After  serious  attacks,  recovery  is  a  tedious  process ;  and 
in  aged  and  weakly  subjects  death  is  not  uncommon. 
Chronic  diarrhoea  invariably  leads  to  more  or  less 
serious  disorder  of  nutrition,  as  shown  by  the  loss 
of  flesh  and  anaemia  which  steadily  progress  while 
the  abdominal  symptoms  are  liable  to  variations. 
Diarrhoea  much  aggravates  the  effects  of  other  exhaust- 
ing diseases. 

The  diagnosis  of  diarrhoea  can  never  present  any 
difficulty,  and  the  discovery  of  the  cause,  which  is  all- 
important  as  regards  treatment,  is  generally  easy.  The 
first  question  for  the  physician  to  decide  is  whether  it 
is  desirable  to  check  the  peristaltic  action  upon  which 
the  diarrhoea  depends,  and  the  decision   must  be  guided 


624  TRTIATM^NT  OF  DIARRIKEA. 

by  the  conditions  present  in  any  given  case.  If  the 
patient's  life  is  in  jeopardy  by  reason  of  the  number  and 
profuseness  of  the  evacuations^  there  can  be  no  doubt 
as  to  the  course  to  be  pursued  ;  but  in  the  absence  of 
such  danger,  the  question  will  arise  whether  the  removal 
of  irritating  matters  from  the  intestine  will  not  be  the 
most  rational  way  of  curing  the  diarrhoea.  Such  a 
question  may  have  to  be  solved  not  only  when  dealing 
with  cases  of  diarrhoea  due  to  irritating  ingesta,  but 
also  with  those  in  which  the  discharges  aid  in  removing 
from  the  body  the  infectious  materials  of  such  disorders 
as  typhoid  fever,  septicaemia^  and  the  like.  In  these 
latter  cases  the  course  to  be  pursued  depends  upon  the 
condition  of  the  patient,  and  the  frequency  and  amount 
of  the  discharges.  When  irritating  ingesta  are  present 
their  removal  is  always  desirable,  and  this  is  best 
effected  by  the  use  of  castor  oil,  a  mild,  non-irritating 
purgative.  The  sulphate  of  sodium  is  another  suitable 
remedy  for  this  purpose ;  it  should  be  given  in  half- 
ounce  doses,  dissolved  in  half-a-pint  of  warm  water. 
It  should  not,  however,  be  given  to  weakly  subjects, 
nor  to  cases  in  which  the  discharges  have  been  very 
profuse  and  fluid  in  character.  Rhubarb  is  another 
excellent  remedy   for  these   cases ;  the  dose    is    about 


TREATMENT  OF  DIARRHCEA.  621 


gr.  X,  and  it  may  be  advantageously  combined  with 
so(la_,  magnesia,  and  carminatives. 

When  the  stomach  is  in  an  irritable  condition,  and 
would  reject  either  castor  oil  or  rhubarb,  a  full  dose  of 
calomel  (gr.  v-x  for  adults)  will  prove  the  best  remedy. 
It  quickly  removes  all  offending  materials^  without 
causing  much  depression,  and  it  likewise  tends  to  check 
vomiting. 

When  it  is  deemed- desirable  to  check  the  peristaltic 
action  of  the  bowels  and  thus  arrest  diarrhcea,  opium  is 
the  best  remedy  at  our  command.  The  drug  may  be 
given  either  in  the  solid  form  or  in  that  of  the  tincture^ 
and  small  doses  are  to  be  preferred  to  large  ones.  It  is 
most  conveniently  administered  by  the  mouth  ;  but  for 
severe  cases  the  most  efficacious  way  of  using  opium  is 
the  introduction  of  suppositories  containing  about  a 
grain  of  the  extract.  One  of  these  may  be  employed 
after  each  relaxed  motion,  and  two  or  three  are  usually 
sufficient.  An  enema  containing  laudanum  is  less 
efficacious;  even  a  small  quantity  of  fluid  is  apt  to 
irritate  the  rectum.  When  uneasiness  of  the  stomach 
is  coupled  with  that  of  the  intestines_,  a  few  drops  of 
laudanum  combined  with  such  aromatics  as  Tinct. 
Card.     Co._,    or    Tinct.    Lavandulae,    or    Pulv.     Cretse 

40 


626  TREATMENT  OF  DIARRHCEA. 


Aromat.,  will  be  found  efficacious.  In  so-called  "  sum- 
mer diarrhoea"  it  is  well  to  combine  some  bitter 
astringent  with  the  opium,  and  tincture  of  cinchona  is 
very  suitable  for  this  purpose. 

The  same  combination  (using  tinct.  opii,  nx  iij-v) 
mav  be  continued  during  convalescence ;  given  before 
meals,  it  serves  to  lessen  the  irritability  of  the  stomach 
and  to  check  abnormal  peristaltic  action. 

Astringents    of  various    kinds,    e.g.,  catechu,    kino, 
<'-allic  acid,  acetate  of  lead,  dilute  sulphuric  acid,  chalk, 
and  sulphate  of  copper  are  often  employed   in  cases   of 
diarrhoea;    they    are    suitable  mainly    for  the    chronic 
forms.     Those  which    contain    tannin   should    not    be 
<yiven    in    combination    with    opium,    inasmuch   as    its 
alkaloids    are   thereby    rendered    almost   insoluble.      If 
opium   be   contraindicated   for  any  reason,  the   veget- 
able astringents  may  be   substituted    and   given   either 
with  or  without  chalk.     A  new  remedy,   coto  bark    in 
the  form  of  a  tincture,  is  useful  for  catarrhal   diarrhoea. 
For    summer    diarrhoea,    and    for    cases    in    which  the 
symptoms    continue    after    expulsion    of    the    exciting 
irritant,    spirits  of  camphor,  in    doses  of  four  or  five 
drops  every    ten  minutes  till  the  symptoms    abate,    is 
often  very  efficacious,  and  a  little  brandy  may   be  added 


TREATMENT  OF  BIARRHCEA.  627 

with    advantage.       The    same    drag   is    also    useful    in 
diarrhoea  the  result  of  exposure  to  cold. 

Besides  the   remedies  above  mentioned,  rest  in  bed 
and  warm  applications   to  the  abdomen  will   do  much 
to  check  diarrhoea  and  to   relieve   pain  and  tenderness, 
and  should  never   be   omitted.     A   warm  bath  once  or 
twice  daily  is  very  grateful  to  the  patient,  and  is  especi- 
ally serviceable  when  the  attack  has  been  due  to  cold  ; 
it   should  be   followed  by    a   warm    bed.     The  diet  in 
acute  attacks  should  be  restricted  to  small  quantities  of 
bread  and  milk,  arrowroot   or  sago,  taken    lukewarm. 
If  stimulants  are  necessary,  a  little  warm  brandy  and 
water,     or    claret    and    water,    may    be    administered. 
During  convalescence,    the  greatest    care    is   necessary 
with  regard  to  diet;  the  rules  laid  down  in  the  chapter 
on  Dyspepsia  must  be  put  in  force. 

In  dealing  with  cases  of  chronic  diarrhoea,  the  habits 
of  life  and  diet  of  the  patient  require  minute  attention. 
Every  attempt  should  be  made  to  discover  the  cause 
of  the  complaint,  and  any  errors  which  tend  to  per- 
petuate  it.  The  dietetic  rules  applicable  to  dyspepsia, 
subject  to  such  modifications  as  may  be  required,  should 
be  clearly  prescribed  ;  as  a  general  rule  such  articles  of 
diet  should  be  chosen  as  are  of  a  nutritious  character, 


628  DIASRHGEA  IN  CHILDREN. 

but  leave  a  small  amount  of  faecal  residue.  Warm 
clothing  with  flannel  next  the  skin  should  always  be 
worn,  and  an  extra  piece  of  thin  flannel  or  of  silk  round 
the  abdomen  is  generally  to  be  recommended.  In 
severe  cases_,  and  during  exacerbations  the  patient  should 
be  kept  in  bed,  but  under  more  favourable  circumstances 
suitable  exercise  should  not  be  neglected. 

Diarrhoea  dependent  on  hepatic  derangement  will  be 
described  in  the  succeeding  chapter  of  this  work. 

Tt  is  now  desirable  to  consider  the  subject  of  diarrhoea 
in  connection  with  children,  among  whom  the  com- 
plaint is  extremely  prevalent.  The  younger  the  child, 
the  greater  the  liability  to  disorder  of  the  digestive 
organs,  and  the  attacks  usually  involve  the  entire  intes- 
tinal tract,  and  are  accompanied  with  diarrhoea.  The 
normal  physiological  conditions  are  very  favourable  to 
the  development  of  disorders  of  digestion  in  children  • 
the  organs  charged  with  providing  the  necessary  secre- 
tions are  insuflBciently  developed  in  early  life,  and  it  is 
onlv  by  slow  degrees  that  they  become  equal  to  the 
tasks  laid  upon  them.  Moreover,  the  child  cannot  at 
first  distinguish  between  the  sensations  of  hunger  and 
thirst,  and  for  some  time  is  unable  to  express  its  wants 
otherwise  than  by  crying.     While  still  at  the  breast  its 


DIARRH(EA  IN  CHILDREN.  629 

food  is  such  as  to  satisfy  both  hunger  and  thirsty  but 
the  case  is  very  different  after  weaning.  A  child 
conscious  of  thirst  is  only  too  apt  to  get  such  food  as 
relieves  hunger;  the  alimentary  canal  is  overloaded 
with  materials  in  greater  quantity  than  can  be  dealt  with 
by  the  secretions  :  decomposition  of  the  food  follows, 
with  gastric  and  intestinal  irritation  or  inflammation  as 
an  inevitable  consequence. 

The  influences  of  disorders  of  digestion  upon  young 
children  are  only  too  clearly  manifest ;  their  slight  power 
of  resistance  to  injurious  influences  is  exhibited  by  the 
mortality  ;  a  large  proportion  of  children  die  during  the 
first  year  from  disorders  of  the  digestive  organs.  The 
symptoms  of  these  complaints  are  liable  to  be  compli- 
cated by  certain  others  which  are  never  seen  in  older 
and  stronger  subjects,  and  their  appearance  is  due  to 
the  small  power  of  resistance  possessed  by  the  child's 
tissues.  Among  the  more  serious  of  these  secondary 
phenomena  are  the  formation  of  abscesses  and  the 
spread  of  suppuration  with  the  development  of  much 
unhealthy  pus  :  haemorrhages  into  the  skin  and  mucous 
membranes,  sloughing  in  the  mouth  and  other  parts, 
destructive  inflammation  of  the  eyes,  etc.  It  not  unfre- 
quently  happens  that  the  violence  of  the  attack  itself 


630  DIABRHCEA  IN  CHILDREN. 

produces  fatal  collapse^  and  epidemics  of  this  character 
are  very  liable  to  occur  in  crowded  cities  during  hot 
weather.  Even  milder  forms  of  diarrhoea,  if  continued 
for  any  length  of  time,  may  produce  serious  emaciation 
with  a  fatal  result.  The  child's  organism  suffers  from 
the  withdrawal  of  nutritive  materials  much  more  rapidly 
and  seriously  than  the  system  of  the  adult ;  on  the  other 
hand,  owing  to  its  greater  powers  of  assimilation,  a 
child  under  favourable  circumstances  often  makes  a 
very  speedy  recovery. 

The  treatment  of  diarrhoea  in  children  is  the  more 
difficult  inasmuch  as  opium  is  a  dangerous  remedy  in 
very  young  subjects  who  are  particularly  sensitive  to  its 
action.  Many  a  child  has  been  sent  out  of  the  world 
by  a  dose  or  two  of  "  soothing  syrup""  or  some  such 
nostrum  of  which  opium  is  the  active  constituent.  The 
drug  is,  however,  often  indispensable,  and  it  may  be 
given  to  very  young  children  provided  that  due  care  be 
taken.  For  a  child  under  six  months  the  maximum 
dose  is  half  a  drop  of  laudanum  repeated  in  three  hours 
if  necessary.  Between  six  and  twelve  months,  one 
drop  is  the  dose,  and  for  every  year  a  drop  may  be 
added,  six  or  seven  being  regarded  as  the  maximum. 
In  violent  attacks   all   food  should   be  withheld  for  five 


TREATMENT.  631 


or  six  hours  ;  a  few  drops  of  claret  or  a  drop  or  two  of 
brandy  may  he  given  every  quarter  of  an  hour,  and  the 
child  should  be  placed  in  a  warm  bath  and  kept  there 
for  ten  or  fifteen  minutes,  while  friction  is  applied  to  the 
surface.  The  warmth  often  acts  admirably  by  relieving 
the  venous  congestion  in  the  abdomen.  It  may  be 
applied  in  another  way,  viz.,  by  enveloping  the  body 
in  folds  of  linen  rung  out  of  hot  water,  and  covered 
with  india-rubber  sheeting  over  which  flannel  is  rolled  : 
this  plan  may  also  be  adopted  as  a  supplement  to  the 
bath.  The  child  is  then  placed  in  a  warmed  bed,  and 
if  its  lower  extremities  are  cold  they  should  be  wrapped 
in  flannel.  After  four  hours  have  elapsed,  the  bath 
may  be  repeated,  and  a  longer  interval  may  be  allowed 
if  there  are  signs  of  increased  power  of  the  circulation, 
such  as  moisture  appearing  about  the  skin  of  the  face. 
After  a  period  varying  from  six  to  twelve  hours,  suppos- 
ing the  patient  to  be  an  infant,  attempts  may  be  made 
to  administer  the  mother's  milk;  but  if  this  be  not 
tolerated,  the  wine  should  be  given  every  ten  or  fifteen 
minutes.  For  the  treatment  of  attacks  in  children 
brought  up  by  hand,  a  wet  nurse  is  generally  indis- 
pensable. When  there  are  indications  of  tenesmus,  it 
is  well  to  administer  an  enema  of  warm  water  with  a 


632  DIARRHCEA  IN  CHILDREN. 

little  salt  dissolved  in  it.     Great  gentleness  should  be 
used  in   injecting  the  fluid  which  serves  to  wash  away 
irritating  matters  from  the  bowels.     Should  the  tenesmus 
continue,  a  little  mucilage  of  starch  containing  a  drop  or 
two  of  laudanum  should  be  injected.     Small  doses  of 
calomel    (gr.   y^)    every   three   or  four   hours  are  often 
useful  in  sub-acute  cases  ;  the  mercurial  acts  as  a  local 
disinfectant.     One  caution  is  necessary  in  dealing  with 
infants  suffering  or  recovering  from   diarrhoea,  viz.,  to 
prevent  them  from  distending  their  stomachs  with  the 
breast-milk;  the    child    is    thirsty,   but    its    powers    of 
digestion    are    in    abeyance    and    any    excess    of    food 
becomes  decomposed  and  acts  as  a  poison.     Intervals 
of  from  four  to  six  hours  between  suckling  should  be 
allowed ;  the  number  and  condition  of  the  evacuations 
are  the  best  guide  for  regulating  the  frequency  of  feeding. 
In  dealing  with  chronic  diarrhoea  in  children,  the  regu- 
lation of  the  diet  is  the  main  point  to  be  attended  to.      If 
the  child  be  yet  unweaned,  proper  intervals,  say  of  three  or 
four  hours,  should  be  suffered  to  elapse  between  suckling 
and  especially  if  the  mother  or  nurse  has   much   milk. 
When  artificial  food  is  given,  it  should  be  well  diluted; 
thus  cows'  milk  should  be  mixed  with  twice  its  volume 
of  water,  boiled  and  allowed  to  cool  down,  before  being 


TREATMENT.  633 


administered.      The  child^s   bottle  and   the  articles  in 
which  the  food  is  kept  must  be  scrupulously  cleansed, 
and  plenty  of  fresh  air  is  \  ery  necessary  for  these  cases. 
Flannel   should    be  worn    next  the   skin   and    the  feet 
should    be  kept    warm.     In    older    children    rice-flour, 
arrowroot,  or  baked  flour  may  be  added  to  the  milk  with 
advantage,  and  milk  and  lime-water  is  sometimes  useful. 
When  the  stools  are  offensive  as  well   as  frequent,  a 
little  grey  powder,  with  rhubarb  and  carbonate  of  sodium, 
is  a  good  remedy.     Sour-smelling  frequent  stools  will 
require  chalk,  or  bismuth  in  doses  of  one  or  two  grains. 
The  vegetable  astringents  are  useful  to  check  frequency  ; 
a  drop  or  two'  of  laudanum  will   heighten  their  action. 
For  very  slimy  stools,  especially  if  mixed  with  blood  and 
accompanied  by  pain  and  straining,  the  perchloride   of 
mercury  in  doses  of  gr.  eV  every  two  or  three  hours  will 
be  found  very  efficacious  ;  a  little  Dover's  powder  may 
also    be  given  at  bedtime.     When  the  stools  contain 
lumps  of  half-digested  food  the  liquor  arsenicalis,   in 
doses  of  one  or  two  drops,  should  be  given  before  each 
meal.     During  convalescence  from    diarrhoea,  a  course 
of  the  liquor  ferri  pernitrat.  will  often  prove  very  service- 
able. 


CHAPTER     IX. 

FUNCTIONAL  DISORDERS  OF  THE  LIVER. 

Functions  of  Liver — Secretion  of  Bile,  Formation  of  Glycogen 
AND  Metabolic  Processes  —  Functional  Disorders  —  Hepa- 
TALGiA — Circulatory  Disorder  —  Hyper.-emia,  Causes  and 
Symptoms — Treatment — Biliousness  and  a  Bilious  Attack — 
Causes  and  Treatment — Disorders  of  the  Secretory  Func- 
tion— The  Saliva  as  a  Test — Excessive  Secretion  of  Bile 
— Symptoms  and  Treatment — Diminished  Secretion  of  Bile 
— Symptoms  and  Treatment — Vitiated  Secretion  of  Bile — 
Symptoms  and  Treatment — Disorders  of  the  Metabolic 
Processes — Evidence  that  Urea  is  Formed  in  the  Liver — 
Lith^mia  as  a  Result  of  Functional  Hepatic  Disorder — 
Symptoms,  Causes,  and  Treatment — Albuminuria  in  these 
Cases  —  Its  Causes,  Import,  and  Treatment  —  Cutaneous 
Affections  in   Lith^emia  and  their  Treatment. 

The  liver  discharges  at  least  three  functions,  one  of  which 
is  perfectly  obvious,  while  the  other  two  are  less  apparent, 
but  not  less  real.  In  the  first  place  the  gland  secretes 
bile,  whichj  formed  by  its  cells^  passes  into  the  bile- 
ducts  and  thence  into  the  duodenum.  (3).  The  hepatic 
cells  also  form  glycogen,  which  does  not  escape  by  the 
ducts^  but  in  a  diffusible  form  passes  into  the  blood- 
vessels, and  leaves  the  liver  by  the  hepatic  veins. 
(3).  The  liver  is   largely  concerned   in  the  destruction 


HBPATALaiA.     '  i^y. 


of  albuminous  matters  derived  from  the  blood  and 
tissues^  and  the  formation  of  urea  and  uric  acid.  The 
organ  is  one  of  the  chief  places  in  which  red  blood- 
corpuscles  become  disintegrated  ;  the  hsemo-globin  is 
the  source  of  bile-pigments^  and  the  blood  of  the 
hepatic  vein  contains  fewer  red  corpuscles  than  the 
blood  of  the  vena  portae  (Landois). 

In  the  present  chapter  T  propose  to  consider  disorders 
of  the  liver^  of  a  functional  character_,  and  exhibiting 
the  forms  of  perversions  of  the  nervous,  circulatory, 
secretory^  and  metabolic  processes. 

I.  Nervous  disozder  of  the  liver.  Pain  of  a  neuralgic 
character  is  the  only  recognized  affection  of  the  liver 
coming  under  this  head.  Pains  are  felt  in  the  right 
hypochondrium  and  epigastrium_,  not  connected  with 
any  appreciable  change  in  the  volume  or  position  of  the 
liver.  They  occur  in  paroxysms  ;  are  sometimes  of  a 
dull  character,  sometimes  acute  and  lancinating ;  and 
they  vary  extremely  as  regards  their  duration  and  times 
of  recurrence.  They  may  come  on  daily,  or  at  longer 
regular  or  irregular  intervals  ;  they  may  last  only  a  few 
minutes,  or  mav  continue  to  be  troublesome  for  days  or 
weeks.  They  are  probably  connected  with  a  gouty  or 
rheumatic  habit,  and  especiallv  with  the  former,  in  the 


636        FUNCTIONAL  DISORDFES  OF  THE  LIVER. 

development  of  which  functional  hepatic  disorder  plays 
a  very  important  part.  They  are  distinguishable  from  the 
pain  attendant  upon  inflammation  of  the  liver  by  their 
fugitive  character  and  by  the  absence  of  all  the  other 
signs  of  that  affection,  and  notably  by  the  absence  of 
tenderness  on  pressure.  Firm  pressure^  indeed^  will 
rather  relieve  the  pain  of  hepatalgia.  There  is  neither 
febrile  disturbance  nor  jaundice ;  but  there  may  be 
constipation  and  some  loss  of  appetite^  and  the  attacks 
are  usually  attended  with  much  depression  of  spirits. 

The  treatment  of  hepatalgia  consists  in  the  adminis- 
tration of  purgatives  and  alkalies;  a  few  doses  of  blue 
pill  at  bedtime,  followed  in  the  morning  by  a  teaspoon- 
ful  or  more  of  Carlsbad  salts  dissolved  in  six  ounces  of 
hot  water,  will  generally  prove  efficacious.  If  there  be 
decided  gouty  manifestations  a  little  extract  of  colchi- 
cum  may  be  added  to  the  blue  pill.  Iodide  of  potas- 
sium will  probably  relieve  the  pain  in  rheumatic  sub- 
jects, and  quinine  should  be  given  during  the  intervals. 

II,  Ciirculatoxy  disorder  of  the  liver.  Hyperaemia  of 
the  liver  is  a  common  condition,  and  is  met  with  under 
a  variety  of  circumstances.  The  fluxionary  form  occurs 
during  the  digestion  of  food,  some  of  the  constituents 
of  which  are  absorbed  by  the  radicles  of  the  portal  vein 


HYPEREMIA  OF  THE  LIVER.  637 

and  conveyed  to  the  liver.  The  physiological  process 
resembles  that  of  disease,  and  fails  to  subside  when  an 
excessive  amount  of  nourishment  is  habitually  taken, 
especially  when  at  the  same  time  little  or  no  bodily 
exercise  is  practised.  The  condition  is^  therefore,  very 
common  amoncr  those  who  eat  and  drink  to  excess  and 
lead  idle  or  sedentary  lives.  It  is  also  liable  to  be  pro- 
voked by  the  ingestion  of  stimulating  condiments  and 
by  the  use  of  spirituous  liquors.  As  a  chronic  morbid 
condition,  passive  congestion  of  the  liver  is  a  frequent 
accompaniment  of  circulatory  and  respiratory  disorders, 
of  tumours  in  the  mediastinum  compressing  the  inferior 
vena  cava,  and  of  disorders  of  the  hepatic  veins. 
Chronic  hypersemia  of  the  liver  is  often  the  result  of 
malarial  poisoning,  and  the  organ  is  frequently  congested 
in  cases  of  typhus  and  typhoid  fevers,  and  as  a  con- 
sequence of  exposure  to  heat,  as  during  a  residence  in 
the  tropics  Attacks  of  congestion  of  the  liver  also 
not  unfrequently  result  from  chills,  especially  after  the 
body  has  been  over-heated. 

The  symptoms  of  hypersemia  of  the  liver  vary  according 
to  the  causation  and  the  state  of  fulness  of  the  vessels. 
There  is  generally  a  feeling  of  weight,  tension,  or  oppres- 
sion in  the  right  hypochondrium,  diminution  or  loss  of 


6^8    FUNCTIONAL  DISORDERS  OF  THE  LIVER. 


appetite,  furred  tongue,  nausea,  either  constipation  or 
some  amount  of  diarihoea,  perhaps  a  bitter  taste  in  the 
mouth,  and  a  yellowish  tinge  of  the  eyes,  skin,  and  urine. 
None  of  these  symptoms  are  constant,  but  whenever 
they  exist  signs  of  mental  disturbance  are  often  super- 
added. The  patient  is  apt  to  be  low-spirited,  languid, 
or  drowsy ;  things  in  general  seem  to  be  going  wrong, 
the  feeling  of  despondency  may  perhaps  amount  to 
melancholia,  or  the  symptoms  may  be  those  of 
hypochondriasis.  Sometimes  there  is  shortness  of 
breath,  and  the  patient  from  time  to  time  takes  deep 
inspirations,  so  as  to  relieve  the  congestion  by  pressure 
ou  the  diaphragm.  In  some  cases  there  is  severe  pain, 
shooting  to  the  back  of  the  right  shoulder,  and  down  the 
right  arm.  Some  patients  find  that  lying  on  either  side 
causes  severe  pain.  On  examining  the  hypochondrium 
the  volume  of  the  liver  is  found  to  be  more  or  less 
increased,  and  there  is  considerable  tenderness  on 
pressure.  In  some  instances  the  symptoms  are  quickly 
developed,  and  as  quickly  disappear;  but  in  others, 
and  especially  when  the  causes  remain  in  operation,  they 
assume  a  chronic  character.  Haemorrhoids  are  not 
un frequent  accompaniments  of  hyperaemia  of  the 
liver.     Sometimes    the    condition    is    relieved    by    an 


TREATMENT  OF  HYPERJEMIA.  639 

attack  of  diarrhoea  or  by  a  discharge  of  blood  from  the 
rectum. 

The  treatment  o{  hyperaemiaof  the  Hver  depends  upon 
the  causation.  If  due  to  excessive  indulgence  in  food 
and  stimulants^  the  latter  should  be  entirely  interdicted 
and  the  diet  considerably  reduced^  animal  food  beins; 
either  withdrawn  for  a  time  or  allowed  in  very  small 
quantities.  Exercise  should  be  likewise  enjoined,  and 
warm  baths  will  relieve  the  condition  of  the  liver. 
Saline  purgatives  wdth  alkalies  are  generally  suitable, 
and  a  little  blue  pill  may  be  given  occasionally  at  bed- 
time. Cold  compresses  may  be  applied  w'ith  benefit  to 
the  region  of  the  liver,  and  in  obstinate  cases  superficial 
blistering  is  likely  to  be  of  great  service.  When  the 
symptoms  become  chronic  we  mav  have  recourse  to 
nitro-muriatic  acid'  and  nux  vomica,  paying  due  atten- 
tion to  the  diet,  exercise,  and  state  of  the  skin,  and 
keeping  the  bowels  regular  by  means  of  aloes  or  cascara. 
Exposure  to  cold  should  be  avoided  by  these  patients, 
and  when  the  symptoms  have  passed  off  it  is  well  to 
recommend  the  wearing  of  a  silk  or  flannel  belt  over 
the  hepatic  region.  Such  prophylactic  measures  for 
preventing  recurrences  as  exercise  and  proper  abstinence 
should  never  be  neglected.     For  hepatic  congestion  due 


640        FUNCTIONAL  BISOHDEBS  OF  THE  LIVER. 

to  malaria  quinine  and  nitro-muriatic  acid  are  the  best 
remedies.  The  treatment  of  cases  due  to  organic  disease 
mustj  of  course^  be  guided  by  the  nature  of  the  latter. 

Before  discussins:;  in  detail  the  various  disorders  of 
the  secretory  function  of  the  liver_,  it  seems  desirable  to 
say  a  few  words  upon  the  condition  known  as  ^^  bilious- 
ness/^ and  its  acme,  a  "bilious  attack."  There  are 
perhaps  few  words  more  freely  or  more  indefinitely  used 
by  the  public  at  large  for  describing  ailments  than  these 
two  expressions.  ''  Bihousness  "  is  generally  used  to 
desiiniate  a  form  or  state  of  indigestion^  attended  by  a 
bitter  or  otherwise  nasty  taste  in  the  mouth  and  perhaps 
nausea.  A  "bilious  attack"  implies  a  more  or  less 
severe  explosion  of  gastric  derangement  with  head- 
ache and  vomiting.  Biliousness  is  in  truth  often  due 
to  torpor  of  the  liver  resulting  in  lessened  or  vitiated 
secretion  of  bile,  and  the  symptoms  will  be  described 
under  those  headings. 

A  "  bilious  attack  "  is  generally  the  result  of  gastric 
and  duodenal  catarrh  caused  by  errors  in  diet,  frequent 
indulgence  in  rich  and  highly  seasoned  dishes,  and 
alcoholic  stimulants.  In  some  persons  one  such  repast 
is  followed  by  a  "bilious  attack/'  the  symptoms  of 
which   may  ensue  at  once,  or  not  until   several   hours 


A  BILIOUS  ATTACK.  641 

have  elapsed.  Perhaps  the  patient  goes  to  bed  soon 
after  a  meal  of  the  above  character,  passes  a  restless 
or  feverish  nig^ht,  and  is  altocrether  unrefreshed  when 
morning  comes.  He  is  conscious  of  a  disagreeable 
taste  in  the  mouth,  and  the  tongue  is  foul  and  coated. 
Thirst  is  troublesome,  and  is  but  slightly  relieved  by 
fluids.  Black  spots  float  before  the  eyes  ;  eructations, 
the  flavour  of  which  resembles  the  odour  of  a  rotten 
tgg,  cause  the  patient  much  annoyance.  There  is  more 
or  less  headache,  chiefly  felt  in  the  forehead  and  increased 
bv  moving,  and  especially  by  stooping.  Nausea  is  soon 
succeeded  by  retching  and  vomiting,  the  ejected  matters 
consisting  of  undigested  articles  of  food,  much  frothy 
and  foul-smelling  fluid  and  finally  bile.  The  efforts  at 
retching  are  apt  to  continue  long  after  the  stomach  has 
been  emptied,  but  they  subside  after  a  variable  interval ; 
the  headache  also  passes  ofl',  and  except,  perhaps,  for 
some  amount  of  depression  the  patient  feels  much  as 
usual.  Some  persons  get  quite  accustomed  to  these 
attacks,  and  instead  of  striving  to  prevent  them,  they 
regard  a  blue  pill  and  a  black  draught  as  the  appropriate 
antidote.  They  confess  themselves  to  be  bilious,  and 
attribute  their  attacks  to  ill-behaviour  on  the  part  of  the 
liver.     As  a  matter-of-fact,  the  stomach  is  the  offended 

41 


642         FUNCTIONAL  DISORDJERS  OF  THE  LIVER. 

organ ;  there  is  no  hindrance  to  the  flow  of  bile  and  no 
disorder  of  the  hver  other  than  that  of  a  temporary 
character  due  to  the  errors  in  diet.  It  is^  however^  very 
difficult  to  persuade  patients  that  such  is  the  actual  state 
of  the  case;  ''  biliousness  "  seems  a  far  easier  explana- 
tion, and  is  the  more  welcome  inasmuch  as  scores  of 
"  antibilious  ^'  remedies  are  easily  procurable. 

In  thus  referring  to  a  bilious  attack,  it  is  necessary 
to  remember  that  not  a  few  persons  believe  that  migraine, 
instead  of  being  essentially  a  nervous  malady,  is  the 
result  of  "  bilious  "  disorder.  This  idea  is  supported 
by  the  fact  that  vomiting  and  sometimes  the  ejection  of 
biliary  matters  are  apt  to  occur  during  an  attack  of 
migraine.  The  causes  of  the  latter  affection  have  been 
fully  described  in  a  previous  chapter,  and  while  it  is  true 
that  an  error  in  diet  is  sometimes  the  exciting  cause  of 
an  attack,  it  is  quite  certain  that  migraine  has  no 
necessary  causal  connection  with  the  state  of  the 
stomach.  In  not  a  few  cases  there  are  no  signs  of 
gastric  disorder ;  in  others  the  latter  supervene  some 
hours  perhaps  after  the  first  symptoms  in  the  head,  and 
are  the  result  of  the  nervous  disorder.  Again,  when  the 
attacks  occur  at  regular  intervals,  and  a  paroxysm  is 
nearly  due,  it  may  be  sometimes  brought  on  by  an  error 


THE  SALIVA  AS  A   TEST.  643 

in  diet,  whereas  the  same  error  repeated  a  day  or  two 
afterwards  is  followed  by  no  such  effect.  The|differences 
between  migraine  and  an  ordinary  bilious  attack  due  to 
improper  food  are  so  marked  that  no  observant  person 
can  fail  to  distinguish  between  the  two  conditions. 

With  regard  to  the  symptoms  of  disorders  of  the 
secretory  functions  of  the  liver  a  minute  account  will  be 
given  in  succeeding  paragraphs,  but  there  is  one  test  for 
these  disorders  lately  insisted  on  by  Dr.  S.  Fenwick 
and  well  deserving  of  consideration.  He  believes  that 
the  sulphocyanide  of  potassium  "^  in  the  saliva  is  in- 
creased in  quantity  whenever  an  unusual  demand  is 
made  upon  the  nutritive  organs  by  the  necessities  of  the 
system,  and  these  organs  are  capable  of  answering  to 
the  call ;  but  that  on  the  contrary  the  amount  of  the 
salt  is  diminished  whenever  the  nutritive  organs  are 
unable  to  meet  its  requirements."  The  presence  of  the 
sulphocyanide  in  the  saliva  depends  upon  a  decomposi- 
tion of  the  biliary  salts,  and  inasmuch  as  chronic  con- 
gestion of  the  liver  lessens  its  functional  activity,  the 
salt  is  always  below  the  normal  amount  when  this  con- 
dition exists.  Dr.  Fenwick^s  researches  show  that  any 
circumstance  preventing  the  digestion  or  absorption  of 
the  food  is  accompanied  by  a  diminution  in  the  amount 


644        FUNCTIONAL  DISORDERS  OF  THF  LIVER. 

of  the  salivary  salt,  and  that  the  quantity  of  this  latter 
can  be  accepted  as  a  measure  of  the  activity  of  the  liver, 
duodenum,  and  salivary  glands,  but  mainly  of  the  first 
alone.  For  the  methods  of  testing  the  saliva  the  reader 
is  referred  to  Dr.  Fenwick's  essay.* 

III.    Disoxder  of   the  secretoiy  function  of  the  liver. 

^rhe  secretion  of  the  liver  is  liable  to  three  forms  of 
disorder  ;  it  may  be  excessive,  deficient,  or  vitiated  in 
quality.  Tn  all  these  cases,  other  symptoms,  e.g., 
diarrhoea,  jaundice,  or  constipation,  are  liable  to  result, 
but  evidences  of  the  hepatic  disorder  of  secretion,  as 
shown  by  the  state  of  the  alvine  evacuations,  may  be 
for  some  time  the  only  manifestation. 

(i).  Excessive  secretion  of  bile  \s  a  common  symptom 
in  hot  climates;  it  may  also  be  caused  by  undue  use  of 
stimulants,  alcoholic  and  otherwise,  and  by  gastric  and 
intestinal  irritation.  In  hot  climates  the  liver  seems  to 
act  vicariously  for  the  lungs  in  carrying  off  excess  of 
carbonaceous  matter.  The  exaltation  of  function  under 
such  circumstances  is  not  of  long  duration,  and  is 
generally  confined  to  the  earlier  years  of  residence. 
Afterwards    an    opposite    condition    is    apt   to  set  in. 


*  "The  Saliva  as  a  Test  for  Functional  Disorders  of  the  Liver,"  by 
Samuel  Fenwick,  M.D.     1887. 


EXCESSIVE  SECRETION  OF  BILE.  645 

and  a  deficiency  of  the  biliary  secretion  becomes 
evident.  Much,  however,  depends  upon  the  habits 
of  Hfe  of  the  individual,  and  especially  upon  the  diet 
and  the  amount  of  exercise  taken. 

The  symptoms  of  excessive  secretion  are  more  or  less 
pain  and  tenderness  in  the  right  hypochondrium,  loss  of 
appetite,  nausea,  and  perhaps  vomiting,  but  especially 
diarrhoea,  with  a  deep  bilious  colour  of  the  evacuations. 
The  latter  are  sometimes  green  from  the  action  of  acid 
in  the  bowels,  are  generally  rather  frequent,  and  at- 
tended with  abdominal  pain  and  a  burning  sensation 
in  the  rectum;  more  or  less  fever  is  generally  present, 
and  the  patient  likewise  complains  of  headache  and 
thirst. 

The  treatment  in  the  early  stage  consists  in  the 
removal  of  the  cause,  rest,  cool  drinks,  and  a  low^  diet. 
Before  diarrhoea  has  set  in  we  may  administer  a  mild 
laxative,  such  as  sulphate  of  sodium  with  an  alkali,  or  a 
little  rhubarb  and  magnesia.  If  diarrhoea  has  already 
occurred  it  may  be  allowed  to  continue  unless  it  become 
excessive,  in  which  case  a  pill  containing  a  quarter  of  a 
grain  of  calomel,  with  one-eighth  of  a  grain  of  opium, 
may  be  given  every  hour  or  two  up  to  eight  doses  if 
necessary.      If  the   purging    should   continue  and   the 


646        FUNCTIONAL  JDISORDJERS  OF  THE  LIVER. 


evacuations  become  pale  a  few  doses  of  chalk  mixture 
with  aromatics  will  serve  to  check  it. 

{%).  Diminished  secretion  of  bile  is  a  common  occur- 
rence, and  sometimes  the  function  seems  to  be  for  a 
time  altogether  in  abeyance.  Such  a  condition  may 
result  from  excessive  stimulation^  followed  by  torpor 
and  exhaustion  of  the  organ.  It  may  also  depend  upon 
an  insufficient  quantity  in  the  blood  of  the  materials 
out  of  which  bile  is  produced.  Other  causes  are  direct 
or  indirect  sedative  agents,  such  as  insufficient  food, 
mental  anxiety,  want  of  exercise,  various  anaemic  condi- 
tions, and  the  diversion  of  nervous  energy  to  other 
organs.  The  state  of  the  liver  is  shown  by  the  colour 
of  the  evacuations,  which  gradually  become  lighter  and 
lighter,  until  at  last  they  resemble  clay,  or  are  almost 
white.  Constipation  is  generally  present,  but  in  some 
cases  of  suppression  of  the  biliary  secretion  diarrhoea  is 
the  prevailing  condition,  the  evacuations  being  usually 
opaque  and  sometimes  almost  milky.  The  discharges 
are  probably  the  result  of  congestion  of  the  intestinal 
mucous  membrane,  consequent  upon  obstructed  circula- 
tion within  the  liver;  the  congestion  is  relieved  by  the 
escape  of  fluid  from  the  distended  vessels.  Suppression 
of  bile  and  the  attendant  diarrhoea  are  usually  accom- 


DIMINISHED  SECRETION  OF  BILE.  647 

panied  by  abdominal  pain  or  uneasiness,  with  gastric- 
derangement,  furred  tongue,  a  foul  taste  in  the  mouth, 
and  depression  of  spirits.  Jaundice  is  not  uncommon, 
especially  in  cases  in  which  there  is  duodenal  catarrh. 

The  treahneni  of  inactivity  of  the  secretory  function 
of  the  liver  is  often  attended  with  difficulties,  and  in 
chronic  cases  the  complaint  is  apt  to  prove  obstinate. 
The  diet  requires  careful  attention  ;  it  should  be  easily 
digestible  and  non-stimulating.  Rich  dishes,  fat,  and 
pastry  of  all  sorts  must  be  interdicted  ;  a  little  claret, 
hock,  or  whisky  may  generally  be  allowed  with  meals; 
they  should  be  well  diluted  bv  some  alkaline  effervescing 
water.  The  patient  should  be  kept  warm,  wear  flannel 
next  the  skin,  and  avoid  chills;  a  few  warm  or  tepid 
baths  are  likely  to  be  serviceable.  With  regard  to 
medicines,  if  constipation  be  present  this  should  be 
corrected  by  means  of  mild  laxatives,  such  as  small 
doses  of  aloes  with  a  little  ipecacuanha  and  nux  vomica  ; 
the  various  saline  purgative  waters  are  also  suitable. 
For  cases  in  which  the  condition  is  the  result  of  over- 
stimulation, as  in  persons  returned  from  the  tropics,  a 
course  of  nitro-muriatic  acid  with  nux  vomica  and  a 
little  henbane  often  yields  most  satisfactory  results  ; 
the  medicine  should  be  continued  for  a  month  or  six 


648        FUNCTIONAL  DISORDERS  OF  THF  LIVER. 

weeks,  all  other  precautions  being  observed  at  the  same 
time.  The  same  remedy  is  often  suitable  for  other 
cases ;  if  it  fail  we  may  have  recourse  to  one  or  more  of 
the  lately  introduced  hepatic  stimulants^viz-^podophyllin, 
iridin,  euonymin,  and  leptandrin.  The  first  of  these 
should  be  given  in  small  doses_,  gr.  xV-i?  night  and 
morning;  if  constipation  exists  it  may  be  combined  with 
aloes.  Iridin  is  another  hepatic  stimulant;  it  is  said  to 
be  more  reliable  than  podophyllin  when  a  slight 
cholagogue  is  wanted  for  a  lengthened  period ;  the  dose 
is  gr.  j-ij  night  and  morning.  Euonymin  and  leptandrin 
possess  like  properties,  and  may  be  given  in  the  same 
doses.  All  these  drugs  are  more  or  less  aperient  in 
their  action.  Other  less  used  remedies  of  the  same 
character  are  hydrastin,  juglandin,  and  sanguinarin. 

Mercury  is  said  to  diminish  the  secretion  of  bile,  and 
yet  cases  are  not  rare  in  which  small  doses  of  this  drug 
seem  to  produce  an  opposite  effect.  Certainly  in 
children  with  clay- coloured,  loose,  offensive  stools  a 
small  dose  of  grey  powder  often  repeated,  or  minute 
doses  of  the  perchloride  will  yield  very  excellent  results, 
checking  the  diarrhoea  and  restoring  the  colour  to  the 
stools.  The  same  remedy  does  good  in  adults  pre- 
senting the  symptoms  of  rapidly-developed  suppression 


VITIATED  SECRETION  OF  BILE.  649 

of  bile^  as  a  result  of  excitement  or  after  exposure  to 
cold  ;  half-a-grain  of  grey  powder  every  three  hours  will 
often  restore  the  secretion. 

(3).  Vitiated  secretion  of  bile.  This  condition,  unless 
very  marked,  is  less  easily  detected  than  either  increase 
or  deficiency  of  the  secretion.  In  extreme  cases  the 
colour  of  the  bile  is  much  altered,  varying  between  a 
deep  bottle-green  and  jet  black.  When  vomited  in  this 
condition  it  is  very  acrid  and  bitter  to  the  taste;  when 
it  passes  off  through  the  bowels  it  causes  diarrhoea  and  • 
severe  colicky  pains  and  burning  sensations  in  the 
rectum.  Similar  disorder  of  a  less  severe  character 
gives  rise  to  irregular  action  of  the  bowels,  with  stools 
of  various  colours  and  foetid  odour;  nausea,  especially 
in  the  mornings,  unpleasant  taste  in  the  mouth,  and  a 
yellowish  fur  about  the  tongue ;  high-coloured  urine, 
with  perhaps  vesical  irritation ;  and  a  yellowish  tinge  in 
the  eyes  and  skin.  The  appetite  is  generally  impaired  ; 
there  is  headache,  general  languor  of  body  and  mind, 
perhaps  irritability  and  depression  of  spirits,  and  dis- 
turbed sleep.  Pains  in  the  back  and  loins,  uneasiness 
under  the  shoulder-blades,  fulness  and  pain  in  the  right 
hypochondrium,  particularly  on  taking  a  full  inspiration, 
are  often  complained  of. 


650        FUNCTIONAL  DISOBBERS  OF  TEF  LIVFR. 

Symptoms  such  as  those  above  described  are  of 
common  occurrence  in  tropical  climates  and  during  hot 
weather  in  this  country.  Thev  are  generally  caused  by 
exposure  to  the  heat  of  the  sun,  indulgence  in  alcoholic 
liquors^  and  rich  and  stimulating  diet.  If  diarrhoea 
occur  the  symptoms  will  probably  soon  pass  off,  but 
repeated  attacks  pave  the  way  for  serious  derangement 
of  the  liver^  especially  in  hot  climates. 

The  treatment  of  cases  of  vitiated  biliary  secretion 
depends  upon  the  cause  of  the  symptom.  If  it  be  due 
to  heat,  the  patient  should  be  kept  quiet  and  as  cool  as 
possible.  A  mild  purgative,  such  as  rhubarb,  with  soda 
and  magnesia,  will  generally  be  serviceable,  and 
effervescing  salines  may  be  afterwards  prescribed.  If 
there  be  irritability  of  the  stomach,  with  nausea  and 
vomiting,  an  emetic  dose  of  ipecacuanha  will  constitute 
the  best  treatment.  The  same  remedy  will  be  suitable 
for  cases  due  to  errors  in  diet,  and  after  the  vomiting 
has  ceased  four  or  five  grains  of  calomel  may  be  given  to 
clear  out  the  bowels.  To  prevent  recurrences,  temper- 
ance and  non-stimulating  diet,  rest,  and  avoidance  of 
exposure  to  heat  are  the  main  points  to  be  attended  to. 
When  the  symptoms  have  become  chronic,  after  atten- 
tion to  the  diet,  we  may  prescribe  with  advantage  the 


DISORDER  OF  METABOLISM.  651 

nitro-mui'iatic  acid  and  warm  baths.  Moderate  exercise 
is  always  serviceable,  and  horse-exercise  is  often  the 
best  form. 

IV.  Disorders  of  the  metabolic  processes  of  which  the 
liver  is  the  seat  still  remain  to  be  described,  and  it  is 
somewhat  remarkable  that  the  views  now  held  as  to  the 
processes  in  question  were  entertained,  though,  of  course, 
somewhat  crudely,  in  very  early  times,  and  were  subse- 
quently forgotten  or  neglected.  Only  within  the  last 
few  decades  has  due  recognition  been  accorded  to  one 
most  important  function  of  the  liver,  viz.,  the  conver- 
sion of  albuminous  matters  derived  from  the  food  and 
tissues  and  the  formation  of  urea  and  uric  acid.  It  is 
the  disorders  of  this  function  that  I  propose  now  to 
consider,  and  in  doing  so  I  cannot  fail  to  allude  to  the 
writings  of  the  late  Dr.  Murchison,*  to  whom  the  pro- 
fession is  much  indebted  for  a  clear  exposition  of  the 
present  state  of  knowledge  on  this  subject  and  the  infer- 
ences to  be  drawn  therefrom.  His  observations  show 
that  the  liver  is  largely  concerned  in  the  formation  of 
urea  and  uric  acid.  For  evidence  in  support  of  this  view 
the  reader  is  referred   to  my  work  on  Gout  and  particu- 


*  "Functional  Derangements  of  the  Liver,"  2nd  edition,  1879. 


6s 2        FUNCTIONAL  DISORDERS  OF  THE  LIVER. 


larly  to  the  chapter  dealing  with  the  causes  of  the  com- 
plaint. It  is,  however,  necessary  to  allude  to  the  main 
points  and  facts  brought  forward  as  evidence. 

In  acute  yellow  atrophy  of  the  liver,  the  secreting 
tissue  is  destroyed  to  a  greater  or  less  extent.  The 
organ  may  be  reduced  to  half  or  even  one-third  its 
normal  bulk  ;  all  traces  of  lobules  and  vessels  are  almost 
or  completely  obliterated.  A  very  important  symptom 
is  connected  with  the  urine,  which  may  be  normal 
in  quantity  and  acid,  but  contains  a  much  reduced 
amount  of  urea,  the  place  of  which  appears  to  be  taken 
by  leucin  and  tyrosin.  Again,  Dr.  Parkes  has  shown 
that  in  cases  of  hepatitis  and  hepatic  abscess^  with 
excessive  suppuration,  the  urea  is  lessened  in  a  degree 
proportionate  to  the  extent  to  which  the  secreting  struc- 
ture is  destroyed  by  the  abscess.  When  the  liver  is  not 
suppurating,  but  actively  congested  and  enlarged,  the 
amount  of  urea  and  uric  acid  seems  to  be  increased.  In 
chronic  congestion  and  in  the  various  forms  of  cirrhosis, 
in  simple  jaundice,  and  in  cases  of  obstruction  from 
gall-stones,  there  is  a  considerable  diminution  in  the 
quantity  of  urea. 

The  interpretation  of  these  pathological  facts  is  sup- 
ported by  some  experiments  recently  made  by  Dr.  Noel 


LITRJEMIA.  653 


Paton  on  the  relationship  of  the  formation  of  urea  and 
uric  acid  to  the  secretion  of  bile.  He  has  shown  that 
stimulation  of  the  flow  of  bile  by  means  of  drugs  is 
accompanied  by  an  increased  production  of  urea,  and 
not  merely  by  an  increased  elimination. 

When  the  transformation  of  albuminous  matters  is 
imperfectly  performed,  the  condition  known  as  lithcemia 
is  a  frequent  consequence.  The  ordinary  cause  of  such 
imperfect  transformation  is  an  excess  of  supply,  com- 
bined as  it  often  is  with  deficient  action  of  the  assimi- 
lating organs.  An  occasional  deposit  of  urates  in  the 
urine  is  a  common  result  of  errors  in  diet^  and  over- 
indulgence at  the  table,  and  is  of  no  serious  import.  If, 
however,  such  a  deposit  be  constantly  or  even  f^requently 
noticed,  it  ought  to  attract  attention,  for  it  indicates 
that  oxidation  is  less  perfect  than  it  ought  to  be,  and 
that  functional  disorder  is  becoming  chronic.  Persons 
are  only  too  apt  to  think  that  the  kidneys  are  ''  out  of 
order,"  but  as  a  matter  of  fact  it  is  not  these  organs, 
but  the  liver,  which  is  generally  at. fault,  and  the  distinc- 
tion as  influencing  the  treatment  is,  of  course,  very 
important. 

When  a  condition  of  lithaemia  has  become  developed, 
certain  symptoms,  perhaps  occasionally  noticed  before. 


654        FUNCTIONAL  DISORDERS  OF  TEE  LIVER. 

are  apt  to  become  prominent.  There  is  more  or  less 
dyspepsia,  as  shown  by  flatulence,  distension,  feelings  of 
uneasiness  or  even  severe  pain  in  the  stomach  and 
duodenum.  The  right  hypochondrium  is  tender  on 
pressure,  and  the  patient  is  conscious  of  a  feeling  of 
weight  and  tension.  Nausea  and  acid  eructations  are 
common  symptoms,  and  there  is  often  a  bitter  taste  in 
the  mouth;  the  tongue  is  furred,  large,  and  indented  at 
the  edges,  the  bowels  are  irregular  and  generally 
constipated,  and  the  skin  has  sometimes  a  slightly 
jaundiced  tinge.  Palpitation  of  the  heart  and  short- 
ness of  breath,  aggravated  by  exertion,  are  often  com- 
plained of,  and  a  short  dry  cough,  attended  with 
excessive  secretion  of  viscid  mucus  in  the  fauces  and 
at  the  back  of  the  nose,  is  sometimes  very  troublesome. 
Haemorrhoids  in  various  stages  are  not  unfrequent,  and 
when  present  are  indicative  of  congestion  of  the  liver. 

As  might  be  expected,  symptoms  of  derangement  of 
the  nervous  system  are  almost  invariably  superadded  to 
those  above  described,  and  in  different  patients  take  the 
forms  of  irritability,  depression,  restlessness,  lassitude, 
drowsiness  after  meals,  headache,  and  inability  for 
mental  exertion.  Sleep  is  broken  and  unrefreshing, 
and    often    disturbed   by  dreams ;  noises  in   the   ears. 


SYMPTOMS  OF  LITH^MIA.  655 

dimness  of  sights  and  vertigo  are  sometimes  very  trouble- 
some and  alarming.  Such  patients  are  apt  to  become 
hypochondriacal^,  feeling  as  they  do  more  or  less  dis- 
comfort in  every  part  of  the  body.  Aching  pains  in 
the  back  and  limbs,  attacks  of  migraine  and  of  facial 
or  other  forms  of  neuralgia  tend  still  further  to  depress 
the  patient.  As  time  goes  on  decided  symptoms  of 
gout  are  wont  to  be  experienced;  the  small  joints  are 
painful  and  tender,  the  eyes  are  hot  and  irritable, 
and  sensations  of  burnins;  and  tingliup;  in  the  hands 
and  feet  cause  much  annoyance.  It  not  unfrequently 
happens  that  after  many  of  the  symptoms  above 
'described  have  existed  for  some  time,  an  acute  attack 
of  gout  supervenes,  and  the  patient  becomes  relieved 
from  his  general  troubles.  But  before  such  a  culmina- 
tion takes  place  the  patient  notices  that  the  symptoms 
are  liable  to  frequent  exacerbations,  and  that  they  are 
always  aggravated  by  errors  in  diet  and  excess  in 
alcohol,  or  even  by  indulgence  in  a  glass  or  two  of 
champagne  or  beer. 

There  are  two  other  symptoms  of  common  occurrence 
among  these  patients ;  the  first  of  these  is  the  appear- 
ance of  a  small  quantity  of  albumen  in  the  urine,  while 
the  second  is  an  eruption  of  eczema.     Further  allusion 


6q6  CAUSES  OF  LITR^MIA. 


will  be  made  to  these  symptoms  in  subsequent  para- 
graphs. 

The  causes  of  lithaemia  require  a  brief  notice;  they 
are  for  the  most  part  connected  with  errors  in  diet. 
Hereditary  tendency  is  also  a  potent  factor  in  their 
development^  and  its  influence  is  often  greatly  promoted 
by  the  patient^s  habits.  Excess  in  albuminous  food  is, 
moreover,  frequently  accompanied  by  deficiency  of 
exercise,  and  the  disproportion  between  the  absorbed 
albuminates  and  the  absorbed  oxygen  must  result  in 
imperfect  oxidation  and  its  consequences,  notably  the 
retention  in  the  system  of  refuse  materials  and  irrita- 
tion of  the  eliminating  organs.  The  nature  and 
digestibility  of  the  food  is  an  important  element  in 
the  consideration.  Malt  liquors  of  all  kinds  and  the 
stronger  and  imperfectly  fermented  wines  play  a  con- 
spicuous part  in  the  causation  of  lithaemia,  and  their 
effects  are  often  superadded  to  those  of  improper  food. 
The  acidity  so  often  complained  of  is  the  result  partly 
of  the  fermentation  of  the  food,  and  partly  of  increased 
secretion  of  gastric  juice.  The  sugars  and  starches  are 
apt  to  undergo  lactic  fermentation  in  the  stomach,  the 
gastric  mucus  acting  as  a  ferment.  The  albuminous 
and  fatty  substances  are  subject  to  butyric  fermentation. 


THEATin^KT  OF  LITn.E2IIA.  657 

and  other  acids,,  such  as   the  acetic,  saccinic^  etc.^  are 
often  developed. 

The  treatment  of  lithaeniia  may  be  described  in  a  few 
words.  The  causes  must  be  avoided;  the  diet  must  be 
reduced  and  suitably  modified ;  and  a  due  amount  of 
exercise  must  be  taken.  The  patient  should  be  provided 
with  diet-rules,  as  described  in'  previous  pages,  and 
every  attempt  should  be  made  to  restore  the  normal 
functions  of  the  liver.  Purgatives  are  generally  indi- 
cated, and  of  these  the  salines  are  the  most  suitable. 
They  may  be  conveniently  administered  in  the  form  of 
such  mineral  waters  as  Friedrichshall,  Hunyadi  Janos^ 
or  Rubinat-Condal,  and  when  much  acidity  and  fermen- 
tation exist  the  Carlsbad  water  or  salts  are  preferable. 
The  various  hepatic  alteratives,  alluded  to  in  previous 
paragraphs,  will  often  be  suitable  for  these  cases,  and 
when  the  urine  contains  much  free  acid,  a  course  of 
alkalies  is  generally  indicated.  The  state  of  the  skin 
always  requires  attention ;  tepid  or  warm  baths  are 
always  beneficial.  For  young  and  plethoric  subjects  an 
occasional  Turkish  bath  will  improve  the  condition  of 
the  skin  and  promote  its  el  i  mi  native  action.  A  course 
of  treatment  at  such  places  as  Bath,  Buxton,  Harrogate, 
Teplitz,or  Vichy  will  almost  always  benefit  chronic  cases. 

4% 


658        FUNCTIONAL  DISORDEES  OF  THE  LITER. 

Disorder  of  the  metabolic  function  of  the  liver  may 
result  not  only  in  lithsemia,  but  likewise  in  a  form  of 
alburninuria,  which  has  attracted  much  notice  during 
the  last  few  years.  I  have  now  observed  this  symptom 
in  many  cases,  the  patients  being  for  the  most  part  men 
in  middle  life,  of  active  literary  habits,  but  somewhat 
free  livers.  The  cases  exhibit  the  ordinary  symptoms 
of  lithsemia  and  gouty  dyspepsia,  but  no  severe  attacks 
of  articular  inflammation.  The  albumen  generally 
occurs  in  very  minute  quantities  ;  but  it  may  vary  from 
one-tenth  to  three  per  cent.  No  casts  are  discoverable, 
and  the  albumen  disappears  in  the  course  of  a  few 
weeks  under  the  use  of  appropriate  diet  and  treatment. 

Albuminuria  is  often  a  very  grave  symptom,  as  it 
generally  indicates  organic  mischief  in  the  kidneys; 
but  in  the  cases  now  alluded  to  I  believe  that  the 
appearance  of  albumen  in  the  urine  is  due  to  defective 
metabolism  of  nutritive  materials  by  the  liver.  There  is 
abundant  evidence  forthcoming  to  show  that  this  sub- 
stance is  often  temporarily  present  in  the  urine  under  a 
great  variety  of  circumstances,  e.g.,  after  excessive 
consumption  of  albuminous  food,  notably  eggs ;  ex- 
posure to  cold  and  wet ;  duriijg  pregnancy ;  after  hard 
mental  toil,  and  nervous  excitement,  and  as  the  result 


ALB  UMIN  URIA.  659 


of  a  gouty  inheritance.  It  is,  doubtless,,  the  "  albumi- 
nuria of  digestion  '^  which  is  present  in  the  cases  now 
before  us ;  some  of  the  albuminous  constituents  of  the 
food  not  being  converted  into  urea,  and  passing  out  of 
the  system  in  an  unchanged  state. 

In  addition  to  the  suspicion  likely  to  be  excited,  this 
excretion  of  albumen,  if  of  frequent  occurrence,  is  very 
liable  to  cause  irritation  of  the  kidneys.  In  his  treatise 
on  albuminuria,  Dr.  Senator  points  out  that  when  egg- 
albumen,  as  such,  finds  its  way  into  the  blood,  it  is 
excreted  by  the  kidneys ;  "  but  frequently  this  is  not  all 
that  happens,  for  more  albumen  is  excreted  than  is 
introduced ;  as  a  matter  of  course,  not  more  egg- 
albumen,  but  a  form  which  possesses  the  properties  of 
the  ordinary  albuminous  substances  of  the  serum 
(serum-albumin  and  globulin)/'  Doubtless  the  same 
result  follows  the  frequent  passage  through  the 
kidneys  of  other  albuminous  matters  imperfectly  meta- 
morphosed, and  hence  it  is  that  functional  disorder  of 
the  liver  may  give  rise  to  organic  renal  disease. 

The  treatment  of  albuminuria,  occurring  under  the 
conditions  above  described,  is  practically  the  same  as 
that  of  lithaemia;  the  diet  especially  will  demand  very 
careful  attention.     If  there  be  evidences  of  renal  con- 


66o        FUNCTIONAL  JDISORDJERS  OF  THF  LIVER. 

gestlon,  SLicli  as  pain  in  the  loins^,  frequent  micturition 
and  highly  concentrated  urine,  in  addition  to  saline 
purgatives  and  alkalies,  we  should  prescribe  warm 
baths,  warm  fomentations,  or  mustard  plaisters  to  the 
loins,  and  besides  these  remedies  I  can  strongly 
recommend  dry  cupping  over  the  loins,  repeated  from 
time  to  time  if  necessary.  The  albumen  rapidly 
diminishes  under  this  treatment,  but  its  presence 
must  never  be  disregarded,  for  if  neglected  it  may 
cause  serious  lesions  of  the  kidney. 

The  eczema,  which  is  often  a  troublesome  symptom 
in  connection  with  lithaemia,  would  appear  to  be  due  to 
the  accumulation  in  the  blood  of  certain  excrementitious 
materials,  of  which  uric  acid  is  the  one  most  easily 
demonstrable.  When  the  quantity  of  these  products 
existing  in  the  blood  is  greater  than  can  be  remov^ed  by 
the  kidneys,  the  work  is  thrown  upon  other  organs,  and 
especially  upon  the  skin,  and  the  result  in  many  cases 
is  an  outbreak  of  eczema  or  psoriasis. 

For  the  treatment  of  these  cutaneous  affections  con- 
stitutional remedies  are  always  required,  and  those 
which  stimulate  the  hepatic  functions  are  generally 
serviceable.  The  diet  will  demand  very  careful  atten- 
tion, and  purgatives,  alkalies,  and  tonics  must  be  given 


CUTANEOUS  AFFECTIONS .  G(m 

according  to  circumstances.  Warm  baths  are  generally 
serviceable,  and  arsenic  or  antimonv  may  be  tried  for 
obstinate  cases.  The  itching  is  best  relieved  by  an 
ointment  of  boric  acid,  but  it  must  always  be  remem- 
bered that  relief  is  often  temporary,  and  that  the 
complaint  is  very  apt  to  recur. 


INDEX. 


A. 

Albuminuria,  as  a  functional  disorder  of  the  liver,  658  ;  treatment  of, 

659- 

Angina  pectoris,  407  ;  cardiac  pain  in,  409;  causes  of,  413  ;  diagnosis 
of,  419  ;  lesions  accompanying,  415  ;  pathogeny  of,  415  ;  prognosis 
of,  419  ;  radiation  of  pain  in,  410;  respiratory  symptoms  in,  409; 
symptoms  of,  408  ;  treatment  of,  419  ;  vaso-motor  disorder  in,  411. 

Anorexia,  nervous,  543. 

Aphonia,  426  ;  causes  of,  426  ;  treatment  of,  428. 

Appetite,  excessive,  540  ;  loss  of,  543  ;  perversions  of,  540  ;  vitiated,  545. 

Articular  neuralgia  (see  Neuralgia  of  the  joints),  260. 

Asthma,  448 ;  causes  of,  449 ;  diagnosis  of,  462  ;  essential,  450 ; 
laryngeal  (see  Laryngismus  Stridulus),  439  ;  pathogeny  of,  459  ; 
prognosis  of,  465  ;  sequelae  of,  462  ;  symptoms  of,  454 ;  treatment 
of,  466. 

B. 

Bile,  diminished  secretion  of,  646  ;  excessive  secretion  of,  644 ;  vitiated 

secretion  of,  649. 
Bilious  attacks  and  Biliousness,  640. 
Bowels,  neuralgia  of  the,  581  ;  normal  action  of  the,  590. 

C. 

Causes  of  functional  nervous  disorders,  12. 
Charcoal  as  a  remedy  for  flatulence,  531. 
Chlorosis  in  connection  with  constipation,  594. 


664  INDi:X. 

Chorea  as  an  example  of  the  neuroses,  7,  176;  causes  of,  170;  con- 
nected with  rheumatism,  173;  definition  of,  169;  depending  on 
ocular  disorders,  172;  diagnosis  of,  182;  embolic  theory  of,  174' 
geographical  distribution  of,  170;  heart  disease  in,  181  ;  nature  of, 
173;  prognosis  of,  181  ;  symptoms  of,  186;  treatment  of,  183. 

Circulation,  functional  disorders  of  organs  of,  353. 

Colic,  see  Enteralgia,  572. 

Constipation,  588;  causes  of,  589;  consequences  of,  593;  diagnosis  of, 
600;  hepatic  alteratives  for,  611  ;  laxatives  suitable  for,  606; 
saline  aperients  for,  609  ;  surgical  causes  of,  597  ;  treatment  of, 
601  ;  use  of  enemata  for,  602,  612. 

Cough,  laryngeal,  434. 

D. 

Diarrhoea,  614  ;  causes  of,  615;  diagnosis  of,  623;  in  connection  with 

infectious  disorders,  619;  in  connection  with  intestinal  lesions,  617  ; 

symptoms  of,  612  ;  treatment  of,  623. 
Diarrhoea,  chronic,  treatment  of,  627;  in  children,  628;  treatment  of, 

630. 
Digestion,  functional  disorders  of  organs  of,  481. 
Dyspepsia,  495  ;  acute,  505  ;  and  gastric  catarrh,  497  ;  causes  of,  499  ; 

chronic,   symptoms   of,  507  ;  constipation,  as  a  symptom  of,  511; 

course  and  duration  of,  515  ;  diagnosis  of,  515  ;  prognosis  of,  516; 

pyrosis,  as  a  symptom  of,  5  1 1  ;  results  of,  513;   symptoms  of,  505  ; 

treatment  of,  517  ;  urine,  condition  of,  in,  512. 

E. 

Eczema  due  to  functional  disorder  of  the  liver,  660. 

Enemata  for  relief  of  constipation,  602,  612. 

Enteralgia,  572;  causes  of,  572  ;  diagnosis  of,  578  ;  prognosis  of,  580; 

symptoms  of,  575  ;  treatment  of,  582. 
Epilepsy,  as  an  example  of  the  neuroses,  6;  causes  of,  131  ;  course  of, 

153  ;  definition  of,  129;  diagnosis  of,  155  ;  exciting  causes  of,  137  ; 

geographical  distribution  of,  131  ;  irregular  forms  of,  148;  Jack- 

sonian,    152;    mental    disorder   in,    153;    milder   forms   of,    147; 

morbid  anatomy  and  pathology  of,  138  ;  ocular  defects  as  a  cause 

of,  136  ;  prognosis  of,  157  ;  symptoms  of,  144;  treatment  of,  159; 

of  paroxysms,  166. 


INDEX.  665 


Epileptic  aura,  14-5. 

Epileptic  state,  artificial  production  of,  134. 

Epileptoid  states,  150. 

F. 

Facial  neuralgia  (see  Tic  Douloureux),  216. 

Facial  paralysis,  330;  causes  of,  331  ;  degrees  of,  336;  diagnosis  of, 

337;  loss  of  taste  in,  334;  prognosis  of,  338  ;  symptoms  of,  332; 

treatment  of,  339. 
Food,  improper,  as  a  cause  of  disorder,  486. 
Functional  disorders,  causes  of,  12  ;  characters  of,  22  ;  description  of,  i  ; 

nature  of,  3;  of  the  liver,  634;  of  the  nervous  system,  25;  of  the 

organs"  of  circulation,  353  ;  of  digestion,  481  ;  of  respiration,  425. 

G. 

Gastralgia,  546  ;  causes  of,  547  ;  diagnosis  of,  554;  prognosis  of,  556; 

spasmodic  form  of,  553  ;  symptoms  of,  549;  treatment  of,  556. 
Gastric  disorders  due  to  food,  486. 
Gout  as  a  cause  of   functional  nervous  disorders,   19;    as  a  result  of 

functional  disorder  of  liver,  655.. 

H. 

Hay-asthma,  472  ;  causes  of,  474;  diagnosis  of,  479;  experiments  in 
connection  v^^ith,  475  ;  symptoms  of,  476;  treatment  of,  479. 

Headache,  268;  anaemic,  271;  as  a  symptom,  268;  causes  of,  269; 
character  of  pain  in,  269;  diagnosis  of,  277;  due  tb  optical  dis- 
orders, 275  ;  in  cerebral  hyperaemia,  270  ;  in  gastric  disorder,  273  ; 
in  gout  and  rheumatism,  273;  in  hysteria,  103;  in  neurasthenia, 
272;  in  syphilis,  274;  treatment  of,  278. 

Heart,  functional  disorders  of  the,  353  ;  causes  of,  357  ;  characteristics 
of,  354  ;  murmurs  in,  360  ;  symptom.s  of,  356. 

Heart,  movements  of,  how  regulated,  369, 

Heart,  nervous  supply  of,  362. 

Heart,  palpitation  of  the,  373  ;  causes  of,  377;  diagnosis  of,  382; 
nervous  causes  of,  378;  prognosis  of,  382;  symptoms  of,  374; 
toxic  causes  of,  380  ;  treatment  of,  383. 

Hemicrania  (see  Migraine),  282. 

Hoarseness,  causes  of,  426  ;  treatment  of,  428. 

43 


666  INBJEJ^. 

Hypochondriasis,  341;  causes  of,  342;  course  of,  343;  diagnosis  of, 
348  ;  forms  of,  343  ;  prognosis  of,  347  ;  symptoms  of,  343  ;  treat- 
ment of,  349. 

Hysteria,  82;  causes  of,  84;  course  of,  iii;  contraction  of  joints  in, 
100;  definition  of,  82;  diagnosis  of,  113  ;  disorders  of  circulation 
in,  108;  disorders  of  digestion  in,  106  ;  disorders  of  respiration  in, 
108  ;  disorders  of  secretion  in,  1 10  ;  disorders  of  sensation  in,  102  ; 
disorders  of  uterus  as  causes  of,  85;  duration  of,  11 1;  exciting 
causes  of  attacks,  87;  geographical  distribution  of,  82;  mental 
perversion  in,  89 ;  paralysis  in,  98 ;  paroxysms  of,  92  ;  prognosis 
of,  1 1 2  ;  results  of,  1 1 1  ;  symptoms  of,  88  ;  treatment  of,  1 1 7  ;  treat- 
ment of  paroxysms,  122;  Weir-Mitchell  system  of  treatment,  127. 

Hystero-epilepsy,  95  ;  diagnosis  of  from  epilepsy,  97. 

I. 

Intercostal  neuralgia,  233  ;  causes  of,  233  ;  diagnosis  of,  237  ;  ercptions 
connected  with,  237  ;  points  douloureux  in,  235  ;  radiation  of  pain 
in,  236 ;  symptoms  of,  234  ;  treatment  of,  240. 

Irritable  breast,  or  Mastodynia,  238  ;  diagnosis  of,  240 ;  treatment  of,, 
241. 

L. 

Laryngeal  cough,  434. 

Laryngismus  stridulus,  439  ;  causes  of,  439  ;  diagnosis  of,  444  ;  nature 

of,  443  ;  prognosis  of,  445  ;   symptoms  of,  440  ;  treatment  of,  445. 
Larynx,    application    of    faradism     to,    431  ;     hyperaesthesia    of,    432  ; 

neuralgia  of,  433. 
Liver,    circulatory    disorders    of,    636  ;     functional    disorders     of,     634 ; 

hyperaemia    of,    636  ;     metabolism    in,    651  ;     disorders    of,    653  ; 

secretory  disorders  of,  644  (see  also  Bile). 
Lithaemia,   causes  of,   656  ;  due  to  functional  disorder   of    liver,  653  ; 

treatment  of,  6(57. 

M. 

Metallo-therapeutics,  in  hysteria,  125. 

Migraine,  282;    and  gout,   290;    causes  of,    289;    diagnosis  of,   297  ; 

exciting  causes  of,  291  ;  forms  of,  285  ;  ocular  disorders  in,  287  ; 

pathogeny  of,   293  ;  prodromal  symptoms   of,  283  ;  prognosis   of, 

298  ;    symptoms  of,    284 ;  treatment  of,  298 ;   vaso-motor  disorder 

in,  285. 


INDEX.  667 

N. 
Nerve-prostration,  27  ;  causes  of,  27  ;  diagnosis  of,  41  ;  disorders  of 
circulation  in,  36;  disorders  of  digestion  in,  37;  disorders  of 
respiration  in,  36  ;  duration  of  symptoms  of,  40  ;  electricity  for, 
46. ;  mental  disorder  in,  38  ;  motor  disorder  in,  31  ;  sensory  disorder 
in,  2,3',  sleeplessness  in,  39;  symptoms  of,  31  ;  treatment  of,  42  ; 
varieties  of,  26  ;  vaso-motor  disorder  in,  35  ;  Weir-Mitchell  treat- 
ment of,  47. 
Nervous   dyspepsia,  535  ;  causes  of,  536  ;  diagnosis  of,  538  ;  prognosis 

of^  538  ;  symptoms  of,  536;  treatment  of,  538. 
Nervous  eructations,  568  ;  treatment  of,  570. 
Nervous  vomiting,  560;  causes  of,  561  ;  diagnosis  of,  565  ;  symptoms 

of,  564  ;  treatment  of,  566. 
Neuralgia,  187;  causes  of,  190;  characteristics  of,  189;  diagnosis  of, 
206;  electricity  in  treatment  of,  212;  eruptions  connected  with, 
204;  joints  douloureux  in,  201  ;  radiation  of  pain  in,  200  ;  surgical 
measures  for,  214;  symptoms  of,  196  ;  treatment  of,  208  ;  various 
forms  of,  217;  vaso-motor  disorder  in,  203  (see  also  Intercostal 
Neuralgia,  Sciatica,  and  Tic  Douloureux). 
Neuralgia   of  the   joints,   260;    causes    of,    261;    diagnosis    of,    264; 

symptoms  of,  262  ;    treatment  of,   266. 
Neurasthenia  (see  Nerve-Prostration  and  Spinal  Neurasthenia). 
Neurasthenia  of  the  heart,  401  ;  causes  of,  404;    prognosis   of,   404; 
symptoms  of,  402  ;  treatment  of,  404, 

O. 

Ocular  defects  as  causes  of  functional  nervous  disorders,  20. 
CEsophagus,  spasm  of  the,  488. 

R. 
Respiratory  organs,  functional  disorders  of  the,  425. 

S. 

Saliva,  the,  as  a  test  for  functional  disorders  of  the  liver,  643. 

Sciatica,  242  ;  causes  of,  243  ;  course  of,  250;  diagnosis  of,  251; 
electricity  in  treatment  of,  255  ;  points  douloureux  in,  247  ;  prognosis 
in,  252;  symptoms  of,  245;  treatment  of,  252;  vaso-motor  and 
trophic  symptoms  in,   248. 


668  INDEX. 

Secretion,  gastric  and  intestinal,  perversion  of,  489. 

Secretory  functions  of  liver,  disorders  of,  644. 

Sleeplessness,  causes  of,  71  ;  in  gouty  subjects,  72;  remedies  for,  76 

treatment  of,  75. 
Spinal  irritation,  causes  of,  60 ;  compared  with  spinal  neurasthenia,  63 

diagnosis  of,  64 ;  symptoms  of,  61  ;  treatment  of,  67. 
Spinal  neurasthenia,  causes  of,  58  ;  diagnosis  of,  64  ;  symptoms  of,  58 

treatment  of,  65. 
Syncope,  388 ;  causes  of,  390 ;    duration  of,  389 ;    diagnosis    of,  394 

prognosis  of,  397  ;  symptoms  of,  388  ;  treatment  of,  397. 

T. 

Tannin,  effects  of  on  salivary  digestion,  485. 

Tic  douloureux,  216;  causes  of,  216;  course  of,  226;  diagnosis  of, 
228;  forms  of,  224;  motor  disorder  in,  222;  points  douloureux  in, 
225;  symptoms  of,  220;  treatment  of,  228;  vaso-motor  disorder 
in,  223. 

V. 

Vertigo,  305  ;  as  a  symptom,  305  ;  aural,  311  ;  gastric,  307;  in  de- 
bility, 316  ;  in  epilepsy,  317  ;  in  gout  318  ;  in  neurasthenia,  317  ; 
ocular,  309  ;  pathology  of,  313. 

W. 

Writer's  cramp,  320;  causes  of,  321;  diagnosis  of,  325;  disorders 
allied  to,  325;  forms  of,  322;  pathogeny  of,  321;  prognosis  in, 
325  ;  symptoms  of,  322  ;  treatment  of,  326. 


DATE  DUE 

JA 

M  1  9  1996 

FEB  9     \^ 

FES  2 

S  WOfi 

^yfj 

, 

PrinM 
in  USA 

COLUMBIA  UNIVERSITY  LlBRAm^^ 


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